The impact of delayed nonurgent surgery during the COVID-19 pandemic on surgeons in Alberta: a qualitative interview study

BACKGROUND

During the COVID-19 pandemic, nonurgent surgeries were delayed to preserve capacity for patients admitted with COVID-19; surgeons were challenged personally and professionally during this time. We aimed to describe the impact of delays to nonurgent surgeries during the COVID-19 pandemic from the surgeons' perspective in Alberta.

METHODS

We conducted an interpretive description qualitative study in Alberta from January to March 2022. We recruited adult and pediatric surgeons via social media and through personal contacts from our research network. Semistructured interviews were conducted via Zoom, and we analyzed the data via inductive thematic analysis to identify relevant themes and subthemes related to the impact of delaying nonurgent surgery on surgeons and their provision of surgical care.

RESULTS

We conducted 12 interviews with 9 adult surgeons and 3 pediatric surgeons. Six themes were identified: accelerator for a surgical care crisis, health system inequity, system-level management of disruptions in surgical services, professional and interprofessional impact, personal impact, and pragmatic adaptation to health system strain. Participants also identified strategies to mitigate the challenges experienced due to nonurgent surgical delays during the COVID-19 pandemic (i.e., additional operating time, surgical process reviews to reduce inefficiencies, and advocacy for sustained funding of hospital beds, human resources and community-based postoperative care).

INTERPRETATION

Our study describes the impacts and challenges experienced by adult and pediatric surgeons of delayed nonurgent surgeries because of the COVID-19 pandemic response. Surgeons identified potential health system-, hospital- and physician-level strategies to minimize future impacts on patients from delays of nonurgent surgery.

Protein intake and postprandial hyperglycemia in children and adolescents with type 1 diabetes mellitus, a pilot study

BACKGROUND AND AIMS

To describe the change in glucose and the resulting postprandial hyperglycemia (PPH) that occurs after dietary protein intake (PI) in children with type 1 diabetes (T1D).

METHODS

We conducted a self-controlled, non-randomized, prospective pilot study in children with T1D who were given whey protein isolate drinks (carbohydrate-free, fat-free) of increasing protein amounts (0, 12.5, 25, 37.5, 50, and 62.5 gm) on 6 sequential nights. The glucose levels were monitored with continuous glucose monitors (CGM) and glucometers for 5 h after PI. PPH was defined as glucose elevations over baseline of ≥50 mg/dL.

RESULTS

Thirty-eight subjects were recruited, and eleven subjects (6 females, 5 males) completed the intervention. Subjects had a mean (range) age of 11.6 (6-16) years, diabetes duration of 6.1 (1.4-15.5) years, HbA1c of 7.2 (5.2-8.6) % and weight of 44.5 (24.3-63.2) kg. PPH was detected in 1/11, 5/11, 6/10, 6/9, 5/9, and 8/9 subjects after receiving 0, 12.5, 25, 37.5, 50, and 62.5 gm of protein, respectively.

CONCLUSIONS

In children with T1D, the association between PPH and PI was observed at smaller protein amounts compared to studies done in adults.

Family experiences with palliative care in freestanding paediatric hospices: a scoping review

BACKGROUND

Paediatric palliative care provides supportive care to children with life-threatening or life-limiting illnesses throughout the disease trajectory. Up to 42% of children receiving palliative care in Canada will die within a freestanding paediatric hospice or designated end-of-life care bed. Few studies have assessed families' experiences of this care within freestanding paediatric hospices.

OBJECTIVES

To find and describe literature relating to family experiences in paediatric hospice palliative care throughout the end-of-life care journey including grief and bereavement.

CRITERIA

Inclusion criteria: Children antepartum to 18 years or older if on paediatric palliative care service. Research conducted in freestanding paediatric hospices that focused on families' experiences and perceptions of end-of-life and grief and bereavement care. Full-text articles available in English.

EXCLUSION CRITERIA

Adult palliative and end-of-life care, respite care, palliative care provided in acute or community settings, professional perspectives, unexpected or sudden child death, pregnancy after loss.

SOURCES OF EVIDENCE

Academic Search Complete, CINAHL, Cochrane Database of Systematic Reviews, Embase, PsycINFO, PubMed and Web of Science databases were searched from database inception until the present. Grey literature was also searched for relevant results.

CHARTING METHODS

The scoping review was guided by recommendations from Arksey and O'Malley and Levac et al.

RESULTS

A total of 4250 papers were retrieved, of which 10 met the scoping review criteria. The majority of studies were conducted in the UK. Three major themes emerged: more supportive care for families including grief and bereavement support, the hospice experience itself and future research areas.

CONCLUSIONS

There is little literature that focuses specifically on the needs of families within freestanding paediatric hospices. Further examination of the themes identified above provides an opportunity for future research.

Passive seismic experiment

Seismometer operation for 21 days at Tranquillity Base revealed, among strong signals produced by the Apollo 11 lunar module descent stage, a small proportion of probable natural seismic signals. The latter are long-duration, emergent oscillations which lack the discrete phases and coherence of earthquake signals. From similarity with the impact signal of the Apollo 12 ascent stage, they are thought to be produced by meteoroid impacts or shallow moonquakes. This signal character may imply transmission with high Q and intense wave scattering, conditions which are mutually exclusive on earth. Natural background noise is very much smaller than on earth, and lunar tectonism may be very low.

Seismic data from man-made impacts on the moon

Unusually long reverberations were recorded from two lunar impacts by a seismic station installed on the lunar surface by the Apollo 12 astronauts. Seismic data from these impacts suggest that the lunar mare in the region of the Apollo 12 landing site consists of material with very low seismic velocities near the surface, with velocity increasing with depth to 5 to 6 kilometers per second (for compressional waves) at a depth of 20 kilometers. Absorption of seismic waves in this structure is extremely low relative to typical continental crustal materials on earth. It is unlikely that a major boundary similar to the crustmantle interface on earth exists in the outer 20 kilometers of the moon. A combination of dispersion and scattering of surface waves probably explains the lunar seismic reverberation. Scattering of these waves implies the presence of heterogeneity within the outer zone of the mare on a scale of from several hundred meters (or less) to several kilometers. Seismic signals from 160 events of natural origin have been recorded during the first 7 months of operation of the Apollo 12 seismic station. At least 26 of the natural events are small moonquakes. Many of the natural events are thought to be meteoroid impacts.

Increasing incidence of type 1 diabetes in population from Santiago of Chile: trends in a period of 18 years (1986-2003)

STUDY OBJECTIVE AND SETTING: The aim of this study is to determine the incidence rate of type 1 diabetes in the metropolitan region of Santiago, Chile from 1 January 1986 to 31 December 2003.

DESIGN

Population-based incidence study.

PARTICIPANTS

A case must fulfill the following requirements to be included in this study: age at onset: 0 to 14 years, diagnosed with diabetes and placed on insulin, diagnosed within the defined time period, and to be a resident of the metropolitan region of Santiago at the time of the diagnosis. The population 'at risk' is the population less than 15 years of age.

RESULT

The overall rate of type 1 diabetes was estimated as 4.02 cases per 100 000 children per year (95% confidence interval: 2.98-4.83).

CONCLUSION

The incidence of type 1 diabetes in Santiago, Chile has increased during the last years. This data are concordant with the observation that the incidence of type 1 diabetes is increasing in Latin America and worldwide.

Prevalence of human leukocyte antigen DQA1 and DQB1 alleles in Kuwaiti Arab children with type 1 diabetes mellitus

The prevalence of human leukocyte antigen (HLA) DQB1 and DQA1 alleles has been determined in 78 Kuwaiti Arab children with insulin-dependent diabetes mellitus (IDDM) and in 57 normal healthy controls with similar ethnic background. The typing of HLA-DQ alleles was carried out using an allele-specific DNA-based polymerase chain reaction (PCR) SSP method. DR typing was also performed in 212 control subjects using PCR-SSP (sequence specific primer) method. A significantly higher frequency of DQB1*0201 allele was found in IDDM cases compared to the controls (p<0.001). There was no significant difference in the prevalence of DQB1 alleles *0302, *0501, and *0602 between IDDM cases and the controls. In contrast, DQB1 alleles *0301, *0402, *0502, *0602, and *0603 were represented at a somewhat higher frequency in controls compared to the IDDM cohort. The frequency of DQA1 allele *0301, which encode for an Arg at codon 52, was significantly higher in the IDDM patients compared to the controls (p<0.001). The frequency of DQA1 allele *0302 was also higher in IDDM cases than controls (p = 0.034) but the difference was less pronounced than DQA1*0301. Amongst the Arg52 alleles, no significant difference was detected in the frequency of *0401 between IDDM cases and the controls and the allele *0501 was detected only in controls. For non-Arg52 alleles *0103, *0104, and *0201, the differences in the two groups were not significant, with the exception of allele *0104 (p = 0.024). DR3 was the most common type in the Kuwaiti general population (28%) and DRB1*0301 was detected in 41% of the individuals with DR3 specificity. Analysis of HLA-DQBI/DQA1 haplotypes from IDDM cases and controls revealed a significantly high frequency of haplotype DQA1*0301/DQB1*0201 between Kuwaiti IDDM cases (49/78, 63%) and the controls (8/57, 14%).

Postgraduate programs in molecular epidemiology

Molecular epidemiology is a new field that has recently emerged from the integration of molecular biology into epidemiologic research. As yet, few countries have significant capabilities in molecular epidemiology due to a lack of trained molecular epidemiologists, and a shortage of necessary equipment and supplies. Thus, there is a great need for: 1) training in methods for integrating molecular biology and human genetics into epidemiology and public health, and 2) advanced biotechnology equipment, reagents and supplies for molecular analyses of potential genetic and environmental risk factors. The International Molecular Epidemiology Task Force (IMETAF) was established in 1993, and is actively contributing to the development of training programs, as well as effective technology transfer in several countries. This paper focuses on approaches for enhancing training opportunities in molecular epidemiology, many of which are being supported by IMETAF.

Molecular epidemiology of insulin-dependent diabetes mellitus: WHO DiaMond Project. WHO DiaMond Molecular Epidemiology Sub-Project Group

The WHO DiaMond Molecular IDDM Epidemiology Sub-Project is testing the hypothesis that population variation in the frequency of high-risk HLA-DQ alleles is a primary determinant of the global patterns of IDDM incidence. Data are currently available for 16 populations, and reveal significant variations in the frequencies of HLA-DQA1 and DQB1 alleles among the case and the control groups. However, DQA1 x Arg-(52) and DQB1 x non-Asp-57 (ND) were consistent and independent markers of IDDM susceptibility in all populations, except Japan. Individuals who carried only DQA1 x R and DQB1 x ND alleles had an IDDM risk similar to that observed for first degree relatives of affected individuals (3%-5%). Such information is essential for the development of clinical strategies or disease prevention approaches for the general population or individuals at high-risk. Thus, the DiaMond Molecular Epidemiology Sub-Project provides an excellent model that can be followed to assess the impact of new genetic discoveries on medicine and public health practice for diabetes and other chronic diseases.

Molecular epidemiology of autoimmune thyroid disease

This paper presents preliminary data regarding the prevalence and risk factors for autoimmune thyroid disease in IDDM probands ascertained from the Children's Hospital of Pittsburgh IDDM Registry for 1950-1965 (n = 669). Living IDDM probands who participated in the 1990 follow-up survey (n = 380) were recruited for the Familial Autoimmune and Diabetes Study. Siblings and parents were also invited to participate. To date, 255 IDDM probands and 597 parents and siblings have been evaluated. The diagnosis of autoimmune thyroid disease was based on a clinical evaluation, medical history, and laboratory determinations. Graves disease was rare in this cohort (n = 5). However, Hashimoto's thyroiditis was common among women. Prevalence rates ranged from 54% for IDDM women age < 40 years to 75% for those > 50 years. Corresponding age-specific estimates for female relatives were 22% and 44%, respectively. Approximately one-half of the Hashimoto's individuals were euthyroid; they were more likely to have other autoantibodies and a positive family history than those who were hypothyroid or had no thyroid disease. Genetic analyses revealed a 2-fold increase in DQA1*0501-DQB1*0201 among the Hashimoto's compared to the non-Hashimoto's haplotypes. These findings suggested that Hashimoto's thyroiditis was common in IDDM families, which may be due, in part, to common disease susceptibility genes.

[National survey of the infrastructure of research centers in advanced biotechnology and molecular epidemiology in Mexico]

An International Molecular Epidemiology Task Force group (IMETAF) was established in 1993, where the Mexican group include as their objectives: the evaluation of the main public health problems that could be improvement through molecular epidemiology; the analysis of the interaction between molecular biology and epidemiology; development of international nets of collaboration and the establishment of surveys toward the prevention and control of some diseases. As part of a general strategy the Mexican scientific committee developed the first national infrastructure survey of the centers of biotechnology and molecular epidemiology. This survey obtained data trough a questionnaire of the general characteristics the development of the molecular epidemiology, the main tools of surveys, equipment, material and reagents, the personnel trained in biotechnology, epidemiology and public health, the needs of training, the national and international nets, how to develop molecular epidemiology and areas to be considered. The results give a general idea of the possibilities to develop the field in Mexico. More than 50% are currently working in this theme. The majority in infectious diseases. The centers have the equipment, material reagents and human resources well trained to incorporate the molecular epidemiology in their usual work. They reported the need of technology transfer to develop collaborations and courses, symposia or congresses. We conclude that Mexico has the capability and the infrastructure to develop molecular epidemiology. A survey is needed on animals.

The low prevalence of immunogenetic markers in Korean adult-onset IDDM patients

OBJECTIVE

IDDM is an autoimmune disease that occurs among genetically susceptible individuals. In Asian populations, it is not uncommon for adult patients with NIDDM to eventually lose beta-cell function and develop IDDM. These individuals may be characterized by autoantibodies to GAD and high-risk HLA-DQ alleles, which are unlikely to be prevalent among patients with true NIDDM or in the general population. The objective of the present study was to evaluate and compare the prevalence of these immunogenetic markers in NIDDM patients and healthy nondiabetic individuals from Korea.

RESEARCH DESIGN AND METHODS

The prevalences of anti-GAD antibodies and HLA-DQA1 and DQB1 alleles among 121 patients with newly diagnosed NIDDM identified from a population-based study in Yonchon, Korea, and 100 matched healthy control subjects were evaluated and compared.

RESULTS

The overall prevalence of anti-GAD antibodies was 1.7% (2 of 121) in patients with previously undiagnosed NIDDM, whereas 1 of 100 control subjects had a positive test for antibodies. Among those who tested positive, titers of antibodies to GAD were not high. No statistically significant differences in the distributions of either mean levels of anti-GAD antibodies or DQA1 and DQB1 alleles were found comparing NIDDM patients with control subjects. Interestingly, the frequency of DQB1*non-Asp-57 and DQA1*Arg-52 alleles in the Korean adult control population was similar to that in the U.S. white population (DQB1*non-Asp-57: 0.431 vs. 0.475; DQA1*Arg-52: 0.492 vs. 0.463).

CONCLUSIONS

The low prevalence of anti-GAD antibodies and HLA-DQA1 and DQB1 susceptibility alleles among recent-onset NIDDM patients, which was similar to observations in control subjects, suggests that diabetes in Korean adults is unlikely to have an autoimmune component to its pathogenesis.

So you want to publish in JACH? How to avoid some potholes and pitfallls and make it into print

Many college health professionals are intimidated at the thought of submitting an article to the Journal of American College Health. In this article, the editors provide details about the scope of the journal, describe types of articles it publishes, warn about common errors authors sometimes make in writing and submitting manuscripts for publication, and outline the steps in the review process.

HLA-DQ screening for risk assessment of insulin dependent diabetes in northern Italy

Genetic markers may be used to improve the prediction of insulin-dependent diabetes mellitus (type 1) in individuals with islet autoantibodies. In order to develop a risk assessment strategy for the Lombardy region of northern Italy based on genetic and immunological markers, we analyzed HLA DQA1 and DQB1 alleles in 60 type 1 probands and their first-degree relatives and 65 unrelated control subjects from the same area using polymerase chain reaction (PCR) and oligonucleotide probes. The major risk haplotypes were DQA1 *0501-DQB1*0201 (39.1% of diabetic vs. 8.9% of non-diabetic haplotypes) and DQA1 *0301-DQB1*0302(20% of diabetic vs 7.1% of non-diabetic haplotypes). Stratified analysis showed DQA1*0102-DQB1*0502 also to be associated with type 1 susceptibility when found together with DQA1*0501-DQB1*0201 or DQA1*0301-DQB1*0302. One type 1 patient had the type 1-protective DQA1*0102-DQB1*0602 haplotype. Overall, 88% of patients and 20% of unrelated control subjects had either DQA1*0501-DQB1*0201 or DQA1*0301-DQB1*0302 in the absence of DQA1*0102-DQB1*0602. These data suggest that typing for markers identifying these three haplotypes in the Lombardy population will achieve a sensitivity of almost 90% and exclude 80% of children from subsequent islet autoantibody testing.

The history of psychosurgery

Egas Moniz received the Nobel Prize for Medicine in 1949 for his discovery and popularization of the prefrontal lobotomy. This radical surgery was the product of the progression in our understanding of mental illness, the prevailing attitudes of the times, and the professional rivalry between psychiatrists and neurologists. The prefrontal lobotomy and its modifications, later to be referred to collectively as psychosurgery, offered hope to the mental illness that were previously thought to be incurable. Fueled by "miracle stories" from the popular press, this surgery was performed until the late 1960S. The following article chronicles the early days of psychosurgery, including the factors responsible for its inception and the different techniques used through the years.

Pharmacological activities of spirogermanium and other structurally related azaspiranes: effects on tumor cell and macrophage functions

Spirogermanium is a germanium containing azaspirane which has been shown to have activity in experimental models of cancer and immune dysfunction. A series of analogs of the parent compound were synthesized and evaluated in a number of in vitro and in vivo biological assays to define the structure-activity relationships of this class of compounds relative to their potential therapeutic activities. In a colony-forming assay using HT-29 human colon carcinoma cells various analogs in which carbon replaced germanium (e.g. carbon) retained the potent cytotoxic activity in vitro seen with spirogermanium. Increased cytotoxic potency within the group of carbon containing analogs was directly related to increase in the length of the alkyl group(s) attached to the carbon atom opposite the azaspirane ring structure. DNA and protein synthesis by HT-29 cells was inhibited by these compounds. However, inhibition occurred only at supralethal concentrations or after long exposure times with the drug. None of the azaspiranes demonstrated in vivo anti-tumor activity against P388 leukemia or ADJ-PC6 plasmacytoma. The effect of these compounds on macrophage cell function was evaluated in vitro by their ability to modulate superoxide (O2-) production by macrophages. Spirogermanium inhibited the production of O2- by activated macrophages with an IC50 of 5 microM. Although macrophage viability did not appear to be decreased at the respective IC50 concentrations, the rank order potency for the analogs in the O2- production assay was directly proportional to that measured for their cytotoxic potency in the HT-29 colony formation assay. The results demonstrate that, within this class of compounds, (1) potent biological activity does not require the presence of germanium in the structure; (2) in vitro cytotoxic activity does not appear to be a direct result of the inhibition of macromolecular synthesis, and (3) macrophage function can be modulated in vitro at non-cytotoxic concentrations. These results are discussed in context with the reported anti-tumor activity of spirogermanium and the potential anti-arthritic and immunomodulatory activity of this class of compounds.

Radical neck dissection: a subjective and objective evaluation of postoperative disability

Nearly all patients who undergo radical neck dissection note significant morbidity if the XIth cranial nerve is sacrificed. Physicians can be misled to believe in a lower morbidity because the usual physical examination is unreliable in detecting weakness and because patients rarely persist in mentioning shoulder problems during follow-up visits. Eleven patients between the ages of 55 and 70, who had undergone unilateral neck dissection with sacrifice of the XIth cranial nerve, were given questionnaires and were objectively evaluated for strength and active range of motion on a Cybex II dynamometer. Eighty-two percent of patients experienced pain, 91% experienced weakness, and 91% experienced impairment on the affected side. Peak torque for the affected side ranged between 0 to 85% of the peak torque for the normal shoulder. Gravity-free active range of motions were 20 degrees to 162 degrees with 8 of 11 at 100 degrees or less. In all but two patients, the passive range of motion was limited by pain.

Why do children with diabetes die?

While the treatment of children with Type I diabetes mellitus has dramatically improved since the introduction of insulin in 1922, significant acute mortality still remains. To better ascertain the causes of death in younger children and adolescents with diabetes mellitus, a retrospective review was undertaken of diabetes associated mortality in the patient population followed at the Children's Hospital of Pittsburgh between the years 1950 and 1985. Fifty-five deaths were identified of which 20 occurred during the initial presentation of diabetes and 35 occurred between 2 months and 11 years following the diagnosis of diabetes mellitus. Diabetic ketoacidosis (DKA) was associated with 64% of the total mortality with 85% of the early onset and 54% of the late onset deaths being ketoacidosis related. Of these ketoacidosis associated deaths, cerebral edema was documented in 31%, or 20% of the total group mortality. Non ketoacidosis deaths in both early and late onset groups were caused by heterogeneous events. There were no deaths associated with the traditional late vascular complications of diabetes mellitus. Since diabetic ketoacidosis is a potentially preventable acute complication of diabetes mellitus and represented a predominant cause of mortality in these children, early recognition and prompt treatment might substantially reduce childhood mortality in patients with Type I diabetes mellitus.

Correlates of insulin antibodies in newly diagnosed children with insulin-dependent diabetes before insulin therapy

Insulin antibodies, as measured by plasma radiolabeled insulin-binding capacity, were determined in 124 newly diagnosed insulin-dependent diabetic (IDDM) children before and after 1, 3, and 5 days of insulin therapy. Controls were 35 nondiabetic children with plasma insulin binding capacity of 1.0 +/- 0.7%. The patients were divided into three groups according to their plasma insulin-binding capacity. Group 1 (N = 79) had binding within two standard deviations (SD) of the control mean, group 2 (N = 20) had insulin binding 2-6 SD above controls, and group 3 (N = 25) showed insulin-binding capacity of more than 6 SD above the control mean. After exogenous insulin therapy, plasma 125I-insulin-binding capacity dropped significantly in both groups 2 and 3, concurrent with significant increases in plasma insulin levels. The three groups differed from each other in that patients in group 3 were significantly younger than in the other groups and clinically seemed to be more severely dehydrated, as reflected in their higher levels of serum urea nitrogen, plasma glucose, potassium, and elevated pulse rate. The three groups did not differ in respect to sex, HLA-DR antigens, Coxsackie-B antibody titers, islet cell cytoplasmic antibodies, immunoglobulin level, and C-peptide levels. Only two of 446 siblings of IDDM children showed elevated insulin binding, one of whom developed IDDM 6 wk later. The presence of an insulin-binding substance probably representing insulin antibodies in some cases of newly diagnosed IDDM suggests that autoimmunity in this disorder is not limited to the B-cell membrane and cytoplasm and lends further support to the heterogeneity of IDDM.

Hepatitis Bs antigen and liver cancer: A population based study in Kenya

Peers and Linsell (1973) demonstrated a significant association between the incidence of primary liver cancer and ingested aflatoxin in a study in the Muranga district of Kenya. A study of hepatitis B antigen in the same district showed no significant differences between the low altitude area, with a relatively high incidence of primary liver cancer, and the high altitude area with a lower incidence of the tumour. Current evidence is more in favour of aflatoxin playing an important role in the aetiology of primary liver cancer but hepatitis B antigen may play an ancillary role.

New Seismic Data on the State of the Deep Lunar Interior

Direct shear-wave arrivals from seismtic events originating on the far side of the moon are not observed at some of the stations of the Apollo seismic network. These data suggest that the material in the lunar interior at a depth of 1000 to 1100 kilometers is more dissipative for seismic shear waves than the lithosphere above, and possibly exists in a partially molten state akin to the earth's asthenosphere.

Lunar Crust: Structure and Composition

Lunar seismic data from artificial impacts recorded at three Apollo seismometers are interpreted to determine the structure of the moon's interior to a depth of about 100 kilomneters. In the Fra Mauro region of Oceanus Procellarum, the moon has a layered crust 65 kilometers thick. The seismic velocities in the upper 25 kilometers are consistent with those in lunar basalts. Between 25 and 65 kilometers, the nearly constant velocity (6.8 kilometers per second) corresponds to velocities in gabbroic and anorthositic rocks. The apparent velocity is high (about 9 kilometers per second) in the lunar mantle immediately below the crust.

Moonquakes

Although the average rate of seismic energy release within the moon appears to be far below that of the earth, over 100 events believed to be moonquakes have been recorded by the two seismic stations installed on the lunar surface during Apollo missions 12 and 14. With few exceptions, the moonquakes occur at monthly intervals near times of perigee and apogee and show correlations with the longer-term (7-month) lunar gravity variations. The repeating moonquakes are believed to occur at not less than 10 different locations. However, a single focal zone accounts for 80 percent of the total seismic energy detected. This active zone appears to be 600 kilometers south-southwest of the Apollo 12 and 14 sites and deep within the moon. Each focal zone must be small (less than 10 kilometers in linear dimension) and fixed in location over a 14-month period. Cumulative strain at each location is inferred. Thus, the moonquakes appear to be releasing internal strain of unknown origin, the release being triggered by tidal stresses.