Abstract: Absorbent articles that include elastics in multiple layers are disclosed herein.

Abstract: A disposable absorbent article may include a first waist region, a second waist region, a crotch region disposed between the first and the second waist regions, and a chassis having a topsheet, backsheet, absorbent core, and chassis periphery. The chassis periphery has a varying width, Wv.

Abstract: Disclosed is an absorbent core composite for a disposable absorbent article. The absorbent composite has a first fabric, a body side second fabric, and a plurality of aggregates of superabsorbent particles (SAP) situated between the first fabric second fabric. About each of a plurality of the SAP aggregates, an arrangement of spaced apart bond sites secures the second fabric to the first fabric and form a pocket in which the SAP aggregate is secured between the first fabric and the second fabric. The body side second fabric is a bulky nonwoven including fibers that entangle at least some particles in the SAP aggregate.

Abstract: An artificial urinary sphincter can include a cuff configured to surround a portion of a length of a urethra. An actuator is configured to selectively apply a force to the cuff to thereby apply variable amount of pressure to the urethra. A controller is configured to adjust the application of the force by the actuator to cause the cuff to apply the variable amount of pressure to the urethra. A sensor can be in communication with the controller and configured to detect pressure applied against the cuff by the urethra. The controller is configured to cause the cuff to apply a first closing pressure to the urethra. In response to a detection of a threshold pressure increase by the sensor, the controller is configured to cause the cuff to apply a second closing pressure that is greater than the first closing pressure and that prevents urine from exiting the urethra.

Abstract: The present invention relates to a prosthesis (200) comprising: —one mesh (1) delimited by a peripheral exterior edge (1a), —a frame (2) fastened to said mesh and adopting the shape of said peripheral exterior edge of the mesh, said frame being set back from said peripheral exterior edge and being provided with two hinge points (3a, 3b), the line passing through said two hinge points also passing through the centre (1b) of the mesh and thus forming a line M for folding the mesh in two, characterized in that said prosthesis further comprises at least two anchor pieces (5) made of suturable material and located on a single face of the mesh (1) on either side of said folding line, each piece having a fixed part (5a) linked to said mesh and a free part (5b), said free part being linked to at least one thread-shaped element (7).

Abstract: Aspects of the disclosure relate to “wet” transcatheter prosthetic heart valve or other implant packaging and assemblies in which a prosthetic heart valve or other implant is loaded into a first portion of a delivery device and positioned within a container in which sterilizing fluid is retained to sterilize interior portions of the container as well as provide moisture to prevent the implant from drying out. The disclosure also relates to methods of sterilizing the disclosed assemblies. Some disclosed methods include at least two sterilizing steps and adjustment of a mechanical seal member or formation of multiple seals so that areas proximate the seals are also sterilized during the sterilization process.

Abstract: A graft preparation system includes a fixation implant including a strand of suture wrapped around a graft preparation card. A tenaculum includes a first arm having a first tooth and a second arm having a second tooth that are pivotally connected at a pivot. The first arm includes a slot between the first tooth and the pivot that receives the graft preparation card. A tape suture assembly includes a tape suture and a first suture strand. The tape suture is positioned on a graft, and the tape suture is attached to the graft with a stitch formed with the first suture strand.

Abstract: Funnel-trap type delivery and/or retrieval devices for Inferior Vena Cava (IVC) filters or other medical implants are described in which the devices comprise two layers of braid with an axially support member. The support member may be interposed between braid layers or set inside the braid layers but interposed between heatset features. Delivery and/or retrieval devices, kits in which they are included, methods of use and methods of manufacture are all contemplated herein.

Abstract: A blood filter extraction system for extracting a blood filter from within a blood vessel. The system includes an extraction wire, or plurality of such wires, positioned within an elongated tubular member. A plurality of extraction wires coupled to the distal end of the extraction member each include a hook for engaging filter members. Alternatively, the extraction wires may be one or more wires configured in a helical shape which engage filter members when the extraction member is rotated. The system may also include an elongated tubular member with the distal end having a conical shape. To extract a filter, the extraction wires are then pushed out of the tubular member and into the filter members. The extraction member is then withdrawn or rotated so the wires engage and draw in the filter members, after which the catheter is pushed over the conical portion of the tubular member.

Abstract: In some examples, a medical system including a stent configured to be positioned within a ureter of a patient. The stent includes one or more distal petals and/or one or more proximal petals resiliently biased to deploy radially outwards from a stent body. The stent may be configured to position the distal petals in a kidney of a patient and position the proximal petals in a bladder of the patient. The distal petals and/or proximal petals may be configured to resist a migration of the stent within the ureter. The stent may include suture configured to cause the distal petals and/or proximal petals to substantially to collapse for withdrawal of the stent. The medical system may include a sheath to retain the distal petals and/or proximal petals in a collapsed condition during, for example, implantation in the patient.

Abstract: An intraosseous screw for deposit into a bone structure and retaining a soft tissue therein. The intraosseous screw includes a body and a retention member. The body defines an axial cavity in which soft tissue can be deposited and a window that permits the soft tissue to contact the bone structure in which the intraosseous screw is deposited. The retention member is positioned within the axial cavity and at least partially defines an opening through which a suture connected to soft tissue can pass to facilitate anchoring of the soft tissue within the axial cavity. The intraosseous screw can be combined with a passing suture, driver, and/or peg to provide a system for associating soft tissue with a bone structure. The intraosseous screw can be utilized in a method in which soft tissue is deposited into a bone structure after the interosseous screw is fully deposited in the bone structure.

Abstract: A delivery sleeve for assisting delivery of a tissue implant may include an enclosure an orifice, and a throat. A cinching mechanism, which may include a fastener, may be disposed about the throat. The fastener may be used to fasten the cinching mechanism in a cinched configuration to maintain the throat in a closed configuration. The cinching mechanism may include implant-size indicators thereon. A lubricant or lubricious material may be included upon an inner surface of the enclosure. The cinching mechanism may be used to change the configuration of the throat from an open configuration to a closed configuration. The fastener helps maintain the throat in a closed configuration.

Abstract: Absorbable implants can be used to create volume and shape in soft tissues with regenerated tissue. The implants comprise lattices formed from multiple unit cells. Unit cells can be coils or springs, skeletal polyhedrons, foams, or structures derived from mesh and fiber. The implants may be coated or filled with cells and tissues, and preferably with autologous fat graft. The implants are particularly suitable for use in plastic surgery procedures, for example, to regenerate or augment breast tissue following mastectomy or in mastopexy procedures, and can provide an alternative to the use of permanent breast implants in these procedures.

Abstract: Full contour absorbable implants for breast surgery redistribute breast volume between the breast's upper and lower poles in exact and desirable ratios. The implants preferably redistribute breast volume so that the upper pole breast volume is 20-40% of the total volume, and the lower pole breast volume is 60-80% of the total volume. The implants are also designed to provide specific curvatures to the poles of the breast, and to angulate the nipple areolar complex slightly skyward so that the patient's nipple is positioned at an angle above the nipple meridian reference line. The implants are designed to be transitory, with sufficient strength retention to allow transition from support of the breast by the implant to support by regenerated host tissue growing in and around the implants, without any significant loss of support during or subsequent to remodeling. The implants may optionally be used with permanent breast implants.

Abstract: A surgical device for implanting an artificial cornea into an eye can comprise an installation tool comprising an implantation end for receiving a back portion of an artificial cornea. The installation tool can further comprise a drive nut positioned above the implantation end. The surgical device can further comprise a thumbscrew that is received within the drive nut. The thumbscrew can be rotatable relative to the drive nut to adjust a position of the thumbscrew. During an implantation procedure, the implantation end with the back portion of the artificial cornea positioned thereon can be inserted into the eye, and the thumbscrew can be rotated relative to the drive nut to interact against a front portion of the artificial cornea to lock the artificial cornea in place.

Abstract: An apparatus includes an intraocular pseudophakic contact lens having a first optical lens, multiple projections extending from the first optical lens, and multiple anchors partially embedded in or configured to pass through the projections. The anchors are configured to pierce lens material forming a second optical lens of an artificial intraocular lens in order to secure the intraocular pseudophakic contact lens to the artificial intraocular lens. Different portions of the first optical lens have different refractive powers such that a first portion of the first optical lens has a first refractive power and a second portion of the first optical lens has a second refractive power different from the first refractive power.

Abstract: The present disclosure provides an ophthalmic lens (such as an IOL) that is designed to enhance depth of focus for intermediate vision performance, while maintaining distance vision. The lens may include an optic having an anterior surface and a posterior surface disposed about an optical axis. One of the surfaces (e.g., the anterior surface) may have a surface profile involving a superposition of at least three structures or profiles, including a base structure, a phase shift structure having an inner region, an outer region and a transition region, and a zonal structure having an inner power zone and an outer transition zone.

Abstract: The present disclosure provides a three-lens IOL system including a first, anterior lens, a second, posterior lens rigidly connected to the first lens by at least one rigid member such that the second lens is a fixed distance from the first lens along an axis, a third, center, moveable lens positioned between the first lens and the second lens and adapted to move linearly along the axis anteriorly in a direction of the first lens or posteriorly in a direction of the second lens to change an optical power of the system, and an articulating actuator that contacts the moveable lens and a capsular bag of an eye when the IOL system is implanted in the capsular bag, the articulating actuator adapted to move the moveable lens linearly along the axis.

Abstract: Provided is an intraocular lens exchanger for moving a foldable intraocular lens (IOL), the intraocular lens exchanger including: an outer tube having a first passage formed in a forward/rearward direction; an inner tube disposed to be movable along the first passage and having a second passage formed in the forward/rearward direction; and a variable tube extending from a front end of the inner tube to form a variable passage connected to the second passage, in which the variable tube has an extension part having a width that increases forward in an unconstrained state in which the variable tube is not positioned in the first passage, and the extension part is provided to be elastically deformed when the unconstrained state changes to a constrained state in which at least a part of the extension part is received in the first passage.

Abstract: Systems, methods, and apparatuses for inserting an intraocular lens (IOL) into an eye, are provided. The apparatus comprises an IOL cartridge comprising a nozzle, a compartment, a plunger, and a plunger case. The nozzle is in fluid communication with the compartment, and the plunger case is in fluid communication with the compartment. The plunger is disposed within the plunger case. The plunger case includes flexible members extending from an outer surface of the plunger case. The IOL cartridge is configured to removably attach to a handpiece.

Abstract: Prosthetic heart valves, which are collapsible to a relatively small circumferential size for less invasive delivery into a patient and which then re-expand to operating size at an implant site in the patient, include a collapsible/expandable stent-like supporting structure and various components of flexible, sheet-like material that are attached to the supporting structure. For example, these sheet-like other components may include prosthetic valve leaflets, layers of buffering material, cuff material, etc. Improved structures and techniques are provided for securing such other components to the stent-like supporting structure of the valve.

Abstract: A prosthesis for a cardiac valve includes prosthetic leaflets which are intended to functionally replace the native leaflets of a cardiac valve following the implantation of the cardiac prosthesis. The prosthesis also includes a prosthetic member on which there are mounted the prosthetic leaflets and which is intended to take up a stable, predetermined functional configuration in which the prosthetic member and the prosthetic leaflets reproduce the functionally correct configuration for the purpose of the physiological replacement of the native cardiac valve. The prosthetic member is preconfigured so as to move gradually from an altered, temporary functional configuration, in which the prosthetic member has a deformed geometry with respect to the stable, predetermined stable functional configuration, to said stable, predetermined functional configuration.

Abstract: A replacement heart valve has an expandable frame configured to engage a native valve annulus and a valve body mounted to the expandable frame. The valve body can have a plurality of valve leaflets configured to open to allow flow in a first direction and engage one another so as to close and prevent flow in a second direction, the second direction being opposite the first direction.

Abstract: Various features and associated advantages are described for diametrically adjustable support structures, adjustable valve structures, removable/replaceable valve structures, and associated systems and methods. Although some examples are directed toward prosthetic valve that is a conduit having a valve structure, or a “valved conduit” (e.g., used to replace a pulmonary valve and a portion of the corresponding pulmonary artery or an aortic valve and the aortic root), and other examples are directed toward prosthetic valves implanted native valve orifices (e.g., to replace an aortic or mitral valve), the features and advantages of the structures associated with those examples are interchangeable regardless of a particular application for which the examples are described.

Abstract: This document provides devices and methods for the treatment of heart conditions. For example, this document provides prosthetic heart valves and transcatheter heart valve replacement methods. The prosthetic heart valves can be configured into a low-profile configuration for containment within a small diameter delivery sheath. The prosthetic heart valves include can include a valve member attached to a stent frame. In some embodiments, the valve member is a molded biomaterial with a novel shape and resulting performance characteristics. Localized protective covering members can be attached to the stent frame to prevent the valve member from contacting the stent frame as the valve member cycles between its open and closed configurations.

Abstract: Delivery devices for a stented prosthetic heart valve. The delivery device includes a spindle, at least one cord, and a lateral control feature. The cord is tensioned to crimp the prosthesis to a compressed condition for delivery to a target site. Tension is lessened to allow the prosthesis to self-expand. In a tethered and expanded state in which the prosthesis has self-expanded and is connected to the spindle by the cord, the lateral control feature directs the spindle to a prescribed location relative to the prosthesis appropriate for a functional evaluation of the prosthesis. In some embodiments, the spindle is directed to a center of the prosthesis; in other embodiments, the spindle is held at a commissure of the prosthesis. The lateral control features of the present disclosure assume numerous forms.

Abstract: An expandable sheath for transcatheter delivery system is disclosed, including a tube having opposing distal and proximal ends in its axial direction. The distal end is provided with a plurality of support rods arranged at intervals in a circumferential direction of the tube, and the support rods extending axially and having relative converged and flared configurations. More than two connecting strips are provided in the axial direction between two adjacent support rods. The connecting strip extends in a curved path and undulates in the circumferential direction, and undulation degrees of the connecting strips increase sequentially from the proximal end to the distal end. The connecting strip has a first connecting portion and a second connecting portion respectively connected with two adjacent support rods in the circumferential direction, and the first connecting portion and the second connecting portion are located at different axial levels of the tube.

Abstract: A prosthetic tricuspid remodeling annuloplasty ring having two free ends that are upturned in the inflow direction to help avoid unnecessary leaflet abrasion. The free ends are desirably separated across a gap that is large enough to reduce the risk of passing sutures through the conductive system of the heart, yet not too large that support of the septal leaflet of the tricuspid annulus is degraded. The tricuspid ring may have four sequential segments looking from the inflow side and extending in a clockwise direction from a free end located adjacent the antero septal commissure after implant. The ring may define an inflow bulge in the first segment and/or an inflow bulge in the fourth segment that help the ring conform to the natural bulges created by the adjacent aorta, thereby reducing stress and the potential for ring dehiscence.

Abstract: The present disclosure relates generally to the field of medical devices for delivering artificial chordae tendineae in a patient. In an embodiment, an anchor is movable between a delivery configuration and a deployed configuration, the anchor being in the delivery configuration when disposed within a delivery catheter, the anchor being in the deployed configuration when the anchor is moved beyond a distal end of the delivery catheter. When the anchor is in the delivery configuration it has a first outer dimension and when the anchor is in the deployed configuration it has a second outer dimension, the first outer dimension being smaller than the second outer dimension. The anchor is engageable with a papillary muscle or a heart wall when the anchor is in the deployed configuration and is also coupleable to an artificial chordae tendineae to anchor the artificial chordae tendineae to the papillary muscle or heart wall.

Abstract: The present invention relates to an obstructing device comprising a hollow tubular member comprising a. a proximal opening at its proximal end; b. a substantially tubular surface extending distally from said proximal opening; c. a distal end. The obstructing device further comprises a grasping arm extending distally from said opening at the proximal end; wherein the distal end is either closed or comprises a small orifice. The present invention relates to a method of delivery of said device.

Abstract: A conical shaped venous valve structure formed from collagenous mammalian tissue.

Abstract: According to one embodiment, a heart anchor tensioning device includes a main body and an elongate shaft. A tension member or tether may be inserted through a lumen of the elongate shaft to allow the shaft to be advanced over the tension member and within a body while the main body is positioned outside of the body. The device also includes an anchor coupling mechanism that is configured to engage a heart anchor and move the heart anchor into engagement with a first wall of the heart. The anchor coupling mechanism is able to lock the heart anchor to inhibit proximal movement of the heart anchor along the tension member. The device further includes a tension indicating mechanism that provides an indication of a force being applied to the heart anchor by the device.

Abstract: A bone repair composition and methods thereof include bone fibers made from cortical bone in which a plurality of bone fibers are made into various implant shapes conducive to introduction into a patient through minimally invasive surgery. The bone fiber compositions may be in the form of a pellet or cylinder. A method includes producing the bone fiber graft efficiently with control of key parameters of cohesiveness, rehydration and swelling of the bone fiber graft. Another method includes introducing the bone fiber graft into the cannula efficiently. A method is also provided to allow introduction of a bone graft into a patient by placing the implant in a tube and expelling it through the action of a plunger.

Abstract: A femoral component for a prosthesis used in a total knee arthroplasty includes a posterolateral taper on the lateral condyle. The lateral and medial condyles of the femoral component are asymmetric to accommodate for the asymmetry of a resected lateral and medial condyle of a femur. The taper is designed to improve the fit of femoral component on the femur to eliminate or reduce overhang of the femoral component's lateral condyle, thereby reducing pain, irritation, stiffness, soreness, or any other symptoms of an improperly fitting prosthesis.

Abstract: A two-part joint replacement device for replacing damaged soft joint tissue, such as a meniscus or cartilage tissue. In one form, the device may include a free floating soft joint tissue replacement component comprising a first tissue-interface surface shaped to engage a first anatomical (bone and/or cartilage) structure of a joint having damaged soft tissue. The device may also include a free floating rigid base component comprising a second tissue-interface surface shaped to engage a second anatomical (bone and/or cartilage) structure of the joint. The free floating soft joint tissue replacement component may be shaped to slidably interface with the rigid base component. In another form, the free floating soft joint tissue replacement component and the rigid base component are fixed together.

Abstract: A revision knee system has a unique polymeric tibial bearing monobloc defining both a superior condylar articular bearing surface and an inferior tibial bearing face. The inferior tibial bearing face bears directly on tibial cut surface so as to withstand compressive loading force applied to the superior condylar articular bearing surface thereof. The bearing component comprises a polymeric keel extending from the inferior bearing face which engages a higher strength metallic stem inferiorly with respect to the inferior bearing face and which may be configured to engage the stem in a structurally resilient manner despite the lower material strength of polymer as compared to metal.

Abstract: Shoulder joint implants are disclosed herein for use in shoulder reconstruction that are configured to facilitate the inclusion a central bone screw for augmented bone fixation. The implant can include a baseplate (or metaglene) configured to secure a glenosphere or other prosthetic component to the glenoid. To facilitate lateral or proximal insertion of a central bone screw through the implant, a throughbore defined along the central axis of the metaglene can be widened to accommodate the maximum diameter of the screw. To enable fixation of the glenosphere to the metaglene, a collet can be configured to engage the smaller diameter of a glenosphere coupling element and inserted into the central throughbore. The collet and the bone screw can be separate parts, thereby making insertion of the bone screw optional. Alternatively, the collet and bone screw can be integrated together to form a unitary construct.

Abstract: Implants, instruments, and methods are presented for fixing adjacent bone portions to promote fusion of the bone portion.

Abstract: A method for growing a channeled spinal implant in situ, using a surgical additive-manufacturing system having a dispensing component, and implants formed thereby. The method can include positioning the dispensing component at least partially within an interbody space, between a first patient vertebra and a second patient vertebra, and maneuvering, in an applying step, the dispensing component within the interbody space and depositing, by the dispensing component, printing material on or adjacent the first vertebra. The applying step includes maneuvering the dispensing component and applying the printing material selectively to form an outer surface of the implant having a channel opening and to form an interior of the implant having at least one elongate channel extending to the opening.

Abstract: A disc replacement device including a first body member with a convex articulation surface and a second body member with a concave articulation surface is disclosed. When operably positioned, the convex articulation surface engages the concave articulation surface to provide for movement therebetween. The disc replacement device also includes a first opening in the first body member and a second opening in the second body member, wherein the openings are angled and extends from the front aspects of the body members through the external surfaces. The disc replacement device further includes at least two bone fasteners for insertion into the first and second openings to secure the disc replacement device to a first and second vertebra. An interbody motion device and fusion implant, as well as a surgical method for implantation are also disclosed.

Abstract: The present disclosure describes an intervertebral disk replacement system. The system can include a tissue-engineered intervertebral disc that is combined with a bioresorbable stabilization system for structural guidance. The system can prevent or reduce intervertebral disk implant displacement and can increase the stiffness when compared to the implantation of the intervertebral disk implant without the stabilization system.

Abstract: Devices and methods for intervertebral spinal fusion of adjacent intervertebral bodies are provided. An intervertebral spacer is positioned within a narrow disc space between adjacent intervertebral bodies of a patient. The spacer is arranged with upper and lower guides. The guides are adapted to simultaneously guide the deployment of upper and lower anchors of an anchoring device into their respective intervertebral bodies. The spacer is also adapted to lock the upper and lower anchors to the spacer in the deployed position.

Abstract: Tibial implants, instruments, systems, and methods of implanting a tibial tray during a knee arthroplasty. The inserter instrument may include a main body with a pair of fixed posterior tabs, a moveable anterior tab body with an anterior tab, and a rotatable shaft for controlling movement of the anterior tab body. When the shaft is rotated, the anterior tab body is translated into an expanded position to lock the inserter to the tibial tray, thereby providing precise positioning of the tibial tray during implantation.

Abstract: Embodiments of the present disclosure include in-situ formed or in-situ-manufactured expandable cages, expandable implants, and additive-manufacturing systems for printing spinal implants in-situ, and methods for printing the same. Some embodiments may include a robotic subsystem including scanning and imaging equipment configured to scan a patient's anatomy. Some embodiments may further include an armature having a dispensing component configured to dispense at least one printing material and a controller. The controller may be configured to control the scanning and imaging equipment to determine a target alignment of a patient's spine, and develop in-situ-forming instructions including an in-situ relocation plan. In some embodiments, the in-situ-forming instructions may be based on the target alignment of the patient's spine and an interbody access space which may only partially provide access to a disc space between adjacent vertebra of the patients spine.

Abstract: An implant-trialing instrument for objectively determining a recommended implant size based at least in part on results of inserting a pressure sensitive trial implant into the intervertebral space. The trial implant instrument can include a handle coupled to a pressure sensitive trial. The handle can include an elongate shaft. The pressure sensitive trial implant can be disposed on a distal end of the elongate shaft and include a superior end plate surface configured to engage a first end plate of a first vertebral body and an inferior end plate configured to engage a second end plate of a second vertebral body. The pressure sensitive trial implant also includes a pressure sensitive film disposed on at least one of the superior end plate and the inferior end plate.

Abstract: The present invention concerns a spinal cage hammer including an elongated body comprising a proximal end and a distal end, the elongated body extending from the proximal end to the distal end and defining a cavity extending from the proximal end to the distal end, the at least one cavity being configured to receive at least one portion of a spinal cage holder for holding a spinal cage. The spinal cage hammer includes an interface wall or surface configured to enter into contact with the spinal cage holder to transfer a force to the spinal cage holder.

Abstract: A self-drilling bone fusion screw apparatus is disclosed which includes at least first and second sliding boxes. A first screw member having a tapered end and a threaded body is disposed within the first sliding box, and a second screw member having a tapered end and a threaded body disposed within the second sliding box. An adjuster adjusts the height of the sliding boxes. The screw members are screwed into vertebral bodies in order to fuse the vertebral bodies together. A plurality of the self-drilling bone fusion screw apparatuses may be attached together and/or integrated via a plate or cage. Also disclosed is a cervical facet staple that includes a curved staple base and at least two prongs attached to the bottom surface of the curved staple base.

Abstract: Methods for forming an expandable tubular body having a plurality of braided filaments including a first filament including platinum or platinum alloy and a second filament including cobalt-chromium alloy. The methods include applying a first phosphorylcholine material directly on the platinum or platinum alloy of the first filament and applying a silane material on the second filament followed by a second phosphorylcholine material on the silane material on the second filament. The first and second phosphorylcholine materials each define a thickness of less than 100 nanometers.

Abstract: A biodegradable in vivo supporting device is disclosed. The in vivo supporting device comprises a biodegradable metal scaffold and a biodegradable polymer coating covering at least a portion of the biodegradable metal scaffold, wherein the biodegradable polymer coating has a degradation rate that is faster than the degradation rate of the biodegradable metal scaffold.

Abstract: A multi-stage stent including a stent body and a bio-erodible material is provided. The stent body can be compressed in an initial state and the bio-erodible material can be coupled to the stent body in a configuration that holds the stent body in an expanded first state, following a first stage expansion from the initial state upon deployment of the stent body. Upon erosion of the bio-erodible material the stent body is released from the first state to expand further in a second stage expansion to a second state.