Cellular mechanisms of neuronal population oscillations in the hippocampus in vitro

A variety of population oscillations, at frequencies approximately 5 Hz up to 200 Hz and above, can be induced in hippocampal slices either by (a) manipulation of the ionic environment, or (b) by stimulation of metabotropic receptors; brief oscillations can even occur spontaneously. In this review, we consider in vitro theta (4-12 Hz), gamma/beta (15-70 Hz), and very fast oscillations (VFO) (>70 Hz). Many in vitro oscillations are gated by synaptic inhibition but are influenced by electrical coupling as well; one type depends solely on electrical coupling. For some oscillations dependent upon inhibition, the detailed firing patterns of interneurons can influence long-range synchronization. Two sorts of electrical coupling are important in modulating or generating various in vitro oscillations: (a) between interneurons, primarily between dendrites; and (b) between axons of pyramidal neurons. VFO can exist in isolation or can act as generators of gamma frequency oscillations. Oscillations at gamma frequencies and below probably create conditions under which synaptic plasticity can occur, between selected neurons-even those separated by significant axonal conduction delays.

Alpha 5 subunit-containing GABAA receptors affect the dynamic range of mouse hippocampal kainate-induced gamma frequency oscillations in vitro

Though all in vitro models of gamma frequency network oscillations are critically dependent on GABAA receptor-mediated synaptic transmission little is known about the specific role played by different subtypes of GABAA receptor. Strong expression of the alpha5 subunit of the GABAA receptor is restricted to few brain regions, amongst them the hippocampal dendritic layers. Receptors containing this subunit may be expressed on the extrasynaptic membrane of principal cells and can mediate a tonic GABAA conductance. Using hippocampal slices of wild-type (WT) and alpha5-/- mice we investigated the role of alpha5 subunits in the generation of kainate-induced gamma frequency oscillations (20-80 Hz). The change in power of the oscillations evoked in CA3 by increasing network drive (kainate, 50-400 nm) was significantly greater in alpha5-/- than in WT slices. However, the change in frequency of gamma oscillations with increasing network drive seen in WT slices was absent in alpha5-/- slices. Raising the concentration of extracellular GABA by bathing slices in the GABA transaminase inhibitor vigabatrin and blocking uptake with tiagabine reduced the power of gamma oscillations more in WT slices than alpha5-/- slices (43%versus 15%). The data suggest that loss of this GABAA receptor subunit alters the dynamic profile of gamma oscillations to changes in network drive, possibly via actions of GABA at extrasynaptic receptors.

Coexistence of gamma and high-frequency oscillations in rat medial entorhinal cortex in vitro

High frequency oscillations (> 80-90 Hz) occur in neocortex and hippocampus in vivo where they are associated with specific behavioural states and more classical EEG frequency bands. In the hippocampus in vitro these oscillations can occur in the absence of pyramidal neuronal somatodendritic compartments and are temporally correlated with on-going, persistent gamma frequency oscillations. Their occurrence in the hippocampus is dependent on gap-junctional communication and it has been suggested that these high frequency oscillations originate as collective behaviour in populations of electrically coupled principal cell axonal compartments. Here we demonstrate that the superficial layers of medial entorhinal cortex can also generate high frequency oscillations associated with gamma rhythms. During persistent gamma frequency oscillations high frequency oscillations occur with a high bispectral coherence with the field gamma activity. Bursts of high frequency oscillations are temporally correlated with both the onset of compound excitatory postsynaptic potentials in fast-spiking interneurones and spikelet potentials in both pyramidal and stellate principal neurones. Both the gamma frequency and high frequency oscillations were attenuated by the gap junction blocker carbenoxolone. These data suggest that high frequency oscillations may represent the substrate for phasic drive to interneurones during persistent gamma oscillations in the medial entorhinal cortex.

A role for fast rhythmic bursting neurons in cortical gamma oscillations in vitro

Basic cellular and network mechanisms underlying gamma frequency oscillations (30-80 Hz) have been well characterized in the hippocampus and associated structures. In these regions, gamma rhythms are seen as an emergent property of networks of principal cells and fast-spiking interneurons. In contrast, in the neocortex a number of elegant studies have shown that specific types of principal neuron exist that are capable of generating powerful gamma frequency outputs on the basis of their intrinsic conductances alone. These fast rhythmic bursting (FRB) neurons (sometimes referred to as "chattering" cells) are activated by sensory stimuli and generate multiple action potentials per gamma period. Here, we demonstrate that FRB neurons may function by providing a large-scale input to an axon plexus consisting of gap-junctionally connected axons from both FRB neurons and their anatomically similar counterparts regular spiking neurons. The resulting network gamma oscillation shares all of the properties of gamma oscillations generated in the hippocampus but with the additional critical dependence on multiple spiking in FRB cells.

Interneuron diversity series: inhibitory interneurons and network oscillations in vitro

In vitro models of rhythms of cognitive relevance, such as gamma (30-80 Hz) and theta (5-12 Hz) rhythms in the hippocampus, demonstrate an absolute requirement for phasic inhibitory synaptic transmission. Such rhythms can occur transiently, of approximately 1 s duration, or persistently, lasting for many hours. In the latter case, stable patterns of interneuron output, and their postsynaptic consequences for pyramidal cell membrane potential, occur despite known constraints of synaptic habituation and potentiation. This review concentrates on recent in vitro evidence revealing a division of labour among different subclasses of interneurons with respect to the frequency of persistent rhythms, and the crucial dependence on gap-junction-mediated intercellular communication for the generation and maintenance of these rhythms.

The role of electrical signaling via gap junctions in the generation of fast network oscillations

In recent years, several key studies have shed new light on the roles of electrical signaling via gap junctions between neurons in the adult brain. In particular, it is now clear that electrical signaling is important, if not essential, for the generation of a wide variety of different network interactions which may underlie rhythmic activity, of cognitive relevance, seen in EEG recordings. Two types of such rhythmic activity observed in the hippocampus both in vivo and in vitro are gamma frequency (30-80Hz) oscillations and ultrafast (>80Hz) "ripple" oscillations. Several lines of work, discussed here, show that gap junction-mediated signaling plays a central role in the generation of both these types of network activity. Recent work also now suggests that a number of different, anatomically discrete, gap junction-mediated networks may exist which could both function and be modulated independently.

GABA-enhanced collective behavior in neuronal axons underlies persistent gamma-frequency oscillations

Gamma (30-80 Hz) oscillations occur in mammalian electroencephalogram in a manner that indicates cognitive relevance. In vitro models of gamma oscillations demonstrate two forms of oscillation: one occurring transiently and driven by discrete afferent input and the second occurring persistently in response to activation of excitatory metabotropic receptors. The mechanism underlying persistent gamma oscillations has been suggested to involve gap-junctional communication between axons of principal neurons, but the precise relationship between this neuronal activity and the gamma oscillation has remained elusive. Here we demonstrate that gamma oscillations coexist with high-frequency oscillations (>90 Hz). High-frequency oscillations can be generated in the axonal plexus even when it is physically isolated from pyramidal cell bodies. They were enhanced in networks by nonsomatic gamma-aminobutyric acid type A (GABA(A)) receptor activation, were modulated by perisomatic GABAA receptor-mediated synaptic input to principal cells, and provided the phasic input to interneurons required to generate persistent gamma-frequency oscillations. The data suggest that high-frequency oscillations occurred as a consequence of random activity within the axonal plexus. Interneurons provide a mechanism by which this random activity is both amplified and organized into a coherent network rhythm.

Fast Oscillations and Epilepsy

Very fast oscillations, 80 Hz and greater (designated here VFOs or "ripples") have been observed in the hippocampus and neocortex, under a variety of conditions that are summarized briefly later. VFOs may be of relevance for normal brain function ((1)(2)(3)(4)) and could also be of relevance in the initiation of focal epileptic seizures ((5)(6)). To determine whether such relevance indeed exists, an understanding of the cellular mechanisms of VFOs is essential. For purposes of this commentary, I shall assume that all forms of VFOs are governed by a few common basic underlying principles. Future experimental data may show that assumption to be false, but for now, the assumption at least allows the formulation of straightforward hypotheses that could stimulate experiments.

Sharp wave-like activity in the hippocampus in vitro in mice lacking the gap junction protein connexin 36

Bath application of kainate (100-300 nM) induced a persistent gamma-frequency (30-80 Hz) oscillation that could be recorded in stratum radiatum of the CA3 region in vitro. We have previously described that in knockout mice lacking the gap junction protein connexin 36 (Cx36KO), gamma-frequency oscillations are reduced but still present. We now demonstrate that in the Cx36KO mice, but not in wild-type (WT), large population field excitatory postsynaptic potentials, or sharp wave-burst discharges, also occurred during the on-going gamma-frequency oscillation. These spontaneous burst discharges were not seen in WT mice. Burst discharges in the Cx36KO mice occurred with a mean frequency of 0.23 +/- 0.11 Hz and were accompanied by a series of fast (approximately 60-115 Hz) population spikes or "ripple" oscillations in many recordings. Intracellular recordings from CA3 pyramidal cells showed that the burst discharges consisted of a depolarizing response and presumed coupling potentials (spikelets) could occasionally be seen either before or during the burst discharge. The burst discharges occurring in Cx36KO mice were sensitive to gap junctions blockers as they were fully abolished by carbenoxolone (200 microM). In control mice we made several attempts to replicate this pattern of sharp wave activity/ripples occurring with the on-going kainate-evoked gamma-frequency oscillation by manipulating synaptic and electrical signaling. Partial disruption of inhibition, in control slices, by bath application of the gamma-aminobutyric acid-A (GABA(A)) receptor antagonist bicuculline (1-4 microM) completely abolished all gamma-frequency activity before any burst discharges occurred. Increasing the number of open gap junctions in control slices by using trimethylamine (TMA; 2-10 mM), in conjunction with kainate, failed to elicit any sharp wave bursts or fast ripples. However, bath application of the potassium channel blocker 4-aminopyridine (4-AP; 20-80 microM) produced a pattern of activity in control mice (13/16 slices), consisting of burst discharges occurring in conjunction with kainate-evoked gamma-frequency oscillations, that was similar to that seen in Cx36KO mice. In a few cases (n = 9) the burst discharges were accompanied by fast ripple oscillations. Carbenoxolone also fully blocked the 4-AP-evoked burst discharges (n = 5). Our results show that disruption of electrical signaling in the interneuronal network can, in the presence of kainate, lead to the spontaneous generation of sharp wave/ripple activity similar to that observed in vivo. This suggests a complex role for electrically coupled interneurons in the generation of hippocampal network activity.

Contrasting roles of axonal (pyramidal cell) and dendritic (interneuron) electrical coupling in the generation of neuronal network oscillations

Electrical coupling between pyramidal cell axons, and between interneuron dendrites, have both been described in the hippocampus. What are the functional roles of the two types of coupling? Interneuron gap junctions enhance synchrony of gamma oscillations (25-70 Hz) in isolated interneuron networks and also in networks containing both interneurons and principal cells, as shown in mice with a knockout of the neuronal (primarily interneuronal) connexin36. We have recently shown that pharmacological gap junction blockade abolishes kainate-induced gamma oscillations in connexin36 knockout mice; without such gap junction blockade, gamma oscillations do occur in the knockout mice, albeit at reduced power compared with wild-type mice. As interneuronal dendritic electrical coupling is almost absent in the knockout mice, these pharmacological data indicate a role of axonal electrical coupling in generating the gamma oscillations. We construct a network model of an experimental gamma oscillation, known to be regulated by both types of electrical coupling. In our model, axonal electrical coupling is required for the gamma oscillation to occur at all; interneuron dendritic gap junctions exert a modulatory effect.

Fast rhythmic bursting can be induced in layer 2/3 cortical neurons by enhancing persistent Na+ conductance or by blocking BK channels

Fast rhythmic bursting (or "chattering") is a firing pattern exhibited by selected neocortical neurons in cats in vivo and in slices of adult ferret and cat brain. Fast rhythmic bursting (FRB) has been recorded in certain superficial and deep principal neurons and in aspiny presumed local circuit neurons; it can be evoked by depolarizing currents or by sensory stimulation and has been proposed to depend on a persistent g(Na) that causes spike depolarizing afterpotentials. We constructed a multicompartment 11-conductance model of a layer 2/3 pyramidal neuron, containing apical dendritic calcium-mediated electrogenesis; the model can switch between rhythmic spiking (RS) and FRB modes of firing, with various parameter changes. FRB in this model is favored by enhancing persistent g(Na) and also by measures that reduce [Ca(2+)](i) or that reduce the conductance of g(K(C)) (a fast voltage- and Ca(2+)-dependent conductance). Axonal excitability plays a critical role in generating fast bursts in the model. In vitro experiments in rat layer 2/3 neurons confirmed (as shown previously by others) that RS firing could be switched to fast rhythmic bursting, either by buffering [Ca(2+)](i) or by enhancing persistent g(Na). In addition, our experiments confirmed the model prediction that reducing g(KC) (with iberiotoxin) would favor FRB. During the bursts, fast prepotentials (spikelets) could occur that did not originate in apical dendrites and that appear to derive from the axon. We suggest that modulator-induced regulation of [Ca(2+)] dynamics or of BK channel conductance, for example via protein kinase A, could play a role in determining the firing pattern of neocortical neurons; specifically, such modulation could play a role in regulating whether neurons respond to strong stimulation with fast rhythmic bursts.

Axonal gap junctions between principal neurons: a novel source of network oscillations, and perhaps epileptogenesis

We hypothesized in 1998 that gap junctions might be located between the axons of principal hippocampal neurons, based on the shape of spikelets (fast prepotentials), occurring during gap junction-mediated very fast (to approximately 200 Hz) network oscillations in vitro. More recent electrophysiological, pharmacological and dye-coupling data indicate that axonal gap junctions exist; so far, they appear to be located about 100 microm from the soma, in CA1 pyramidal neurons. Computer modeling and theory predict that axonal gap junctions can lead to very fast network oscillations under three conditions: a) there are spontaneous axonal action potentials; b) the number of gap junctions in the network is neither too low (not less than to approximately 1.5 per cell on average), nor too high (not more than to approximately 3 per cell on average); c) action potentials can cross from axon to axon via gap junctions. Simulated oscillations resemble biological ones, but condition (c) remains to be demonstrated directly. Axonal network oscillations can, in turn, induce oscillatory activity in larger neuronal networks, by a variety of mechanisms. Axonal networks appear to underlie in vivo ripples (to approximately 200 Hz field potential oscillations superimposed on physiological sharp waves), to drive gamma (30-70 Hz) oscillations that appear in the presence of carbachol, and to initiate certain types of ictal discharge. If axonal gap junctions are important for seizure initiation in humans, there could be practical consequences for antiepileptic therapy: at least one gap junction-blocking compound, carbenoxolone, is already in clinical use (for treatment of ulcer disease), and it crosses the blood-brain barrier.

Long-range synchronization of gamma and beta oscillations and the plasticity of excitatory and inhibitory synapses: a network model

The ability of oscillating networks to synchronize despite significant separation in space, and thus time, is of biological significance, given that human gamma activity can synchronize over distances of several millimeters to centimeters during perceptual and learning tasks. We use computer simulations of networks consisting of excitatory pyramidal cells (e-cells) and inhibitory interneurons (i-cells), modeling two tonically driven assemblies separated by large (>or=8 ms) conduction delays. The results are as follows. 1) Two assemblies separated by large conduction delays can fire synchronously at beta frequency (with i-cells firing at gamma frequency) under two timing conditions: e-cells of (say) assembly 2 are still inhibited "delay + spike generation milliseconds" after the e-cell beat of assembly 1; this means that the e-cell inhibitory postsynaptic potential (IPSP) cannot be significantly shorter than the delay (2-site effect). This implies for a given decay time constant that the interneuron --> pyramidal cell conductances must be large enough. The e-cell IPSP must last longer than the i-cell IPSP, i.e., the interneuron --> pyramidal cell conductance must be sufficiently large and the interneuron --> interneuron conductance sufficiently small (local effect). 2) We define a "long-interval doublet" as a pair of interneuron action potentials-separated by approximately "delay milliseconds"-in which a) the first spike is induced by tonic inputs and/or excitation from nearby e-cells, while b) the second spike is induced by (delayed) excitation from distant e-cells. "Long-interval population doublets" (long-interval doublets of the i-cell population) are necessary for synchronized firing in our networks. Failure to produce them leads to almost anti-phase activity at gamma frequency. 3) An (almost) anti-phase oscillation is the most stable oscillation pattern of two assemblies that are separated by axonal conduction delays of approximately one-half a gamma period (delays from 8 to 17 ms in our simulations) and that are firing at gamma frequency. 4) Two assemblies separated by large conduction delays can synchronize their activity with the help of interneuron plasticity. They can also synchronize without pyramidal cell --> pyramidal cell connections being present. The presence of pyramidal cell --> pyramidal cell connections allows, however, for synchronization if other parameters are at inappropriate values for synchronization to occur. 5) Synchronization of two assemblies separated by large conduction delays with the help of interneuron plasticity is not simply due to slowing down of the oscillation frequency. It is reached with the help of a "synchronizing-weak-beat," which induces sudden changes in the oscillation period length of the two assemblies.

A model of atropine-resistant theta oscillations in rat hippocampal area CA1

Theta frequency oscillations are a predominant feature of rhythmic activity in the hippocampus. We demonstrate that hippocampal area CA1 generates atropine-resistant theta population oscillations in response to metabotropic glutamate receptor activation under conditions of reduced AMPA receptor activation. This activity occurred in the absence of inputs from area CA3 and extra-ammonic areas. Field theta oscillations were co-expressed with pyramidal distal apical dendritic burst spiking and were temporally related to trains of IPSPs with slow kinetics. Pyramidal somatic responses showed theta oscillations consisted of compound inhibitory synaptic potentials with initial IPSPs with slow kinetics followed by trains of smaller, faster IPSPs. Pharmacological modulation of IPSPs altered the theta oscillation suggesting an inhibitory network origin. Somatic IPSPs, dendritic burst firing and stratum pyramidale interneuron activity were all temporally correlated with spiking in stratum oriens interneurons demonstrating intrinsic theta-frequency oscillations. Disruption of spiking in these interneurons was accompanied by a loss of both field theta and theta frequency IPSP trains. We suggest that population theta oscillations can be generated as a consequence of intrinsic theta frequency spiking activity in a subset of stratum oriens interneurons controlling electrogenesis in pyramidal cell apical dendrites.

Fast network oscillations induced by potassium transients in the rat hippocampus in vitro

Brief pressure ejection of solutions containing potassium, caesium or rubidium ions into stratum radiatum of the CA1 or CA3 regions of the hippocampal slice evoked a fast network oscillation. The activity evoked lasted approximately 3-25 s with the predominant frequency component being in the gamma frequency range (30-80 Hz), although beta frequency (15-30 Hz) and ultrafast (> 80 Hz) components could also be seen. The gamma frequency component of the oscillation remained constant, even when large changes in power occurred, and was synchronous across the CA1 region. Measurements with potassium ion-sensitive electrodes revealed that the network oscillation was accompanied by increases (0.5 to 2.0 mM) in the extracellular potassium concentration [K+]o. Bath application of the N-methyl-D-aspartate (NMDA) receptor antagonists D(-)-2-amino-5-phosphonopentanoic acid (D-AP5; 50 microM) had no significant effect but the alpha-amino-3-hydroxy-5-methyl-4-isooxazolepropionic acid (AMPA)/kainate receptor antagonist 2,3,-dioxo-6-nitro-1,2,3,4-tetrahydrobenzo[f]quinoxaline-7-sulphonamide disodium (NBQX; 20 microM) caused a significant reduction (86.7 +/- 4.5 %) in the power in the gamma frequency range. Residual rhythmic activity, presumably arising in the interneuronal network, was blocked by the GABA(A) receptor antagonist bicuculline. The putative gap junction blocker octanol caused a decrease in the power of the gamma frequency component of 75.5 +/- 5.6 %, while carbenoxolone produced a reduction of only 14 +/- 42 %. These experiments demonstrate that a modest increase in exogenous [K+]o in the hippocampus in vitro is sufficient to evoke a fast network oscillation, which is an emergent property of the synaptically and electrically interconnected neuronal network.

Fast network oscillations in the rat dentate gyrus in vitro

The dentate gyrus is a prominent source of gamma frequency activity in the hippocampal formation in vivo. Here we show that transient epochs of gamma frequency network activity (67 +/- 12 Hz) can be generated in the dentate gyrus of rat hippocampal slices, following brief pressure ejections of a high-molarity potassium solution onto the molecular layer. Oscillatory activity remains synchronized over distances >300 microm and is accompanied by a modest rise in [K(+)](o). Gamma frequency oscillations were abolished by a GABA(A) receptor antagonist demonstrating their dependence on rhythmic inhibition. However, in many cases, higher frequency oscillations (>80 Hz) remained in the absence of synaptic transmission, thus demonstrating that nonsynaptic factors may underlie fast oscillatory activity.

Gap junctions between interneuron dendrites can enhance synchrony of gamma oscillations in distributed networks

Gamma-frequency (30-70 Hz) oscillations in populations of interneurons may be of functional relevance in the brain by virtue of their ability to induce synchronous firing in principal neurons. Such a role would require that neurons, 1 mm or more apart, be able to synchronize their activity, despite the presence of axonal conduction delays and of the limited axonal spread of many interneurons. We showed previously that interneuron doublet firing can help to synchronize gamma oscillations, provided that sufficiently many pyramidal neurons are active; we also suggested that gap junctions, between the axons of principal neurons, could contribute to the long-range synchrony of gamma oscillations induced in the hippocampus by carbachol in vitro. Here we consider interneuron network gamma: that is, gamma oscillations in pharmacologically isolated networks of tonically excited interneurons, with frequency gated by mutual GABA(A) receptor-mediated IPSPs. We provide simulation and electrophysiological evidence that interneuronal gap junctions (presumably dendritic) can enhance the synchrony of such gamma oscillations, in spatially extended interneuron networks. There appears to be a sharp threshold conductance, below which the interneuron dendritic gap junctions do not exert a synchronizing role.

Self-organized synaptic plasticity contributes to the shaping of gamma and beta oscillations in vitro

gamma (30-70 Hz) followed by beta (10-30 Hz) oscillations are evoked in humans by sensory stimuli and may be involved in working memory. Phenomenologically similar gamma-->beta oscillations can be evoked in hippocampal slices by strong two-site tetanic stimulation. Weaker stimulation leads only to two-site synchronized gamma. In vitro oscillations have memory-like features: (1) EPSPs increase during gamma-->beta; (2) after a strong one-site stimulus, two-site stimulation produces desynchronized gamma; and (3) a single synchronized gamma-->beta epoch allows a subsequent weak stimulus to induce synchronized gamma-->beta. Features 2 and 3 last >50 min and so are unlikely to be caused by presynaptic effects. A previous model replicated the gamma-->beta transition when it was assumed that K(+) conductance(s) increases and there is an ad hoc increase in pyramidal EPSCs. Here, we have refined the model, so that both pyramidal-->pyramidal and pyramidal-->interneuron synapses are modifiable. This model, in a self-organized way, replicates the gamma-->beta transition, along with features 1 and 2 above. Feature 3 is replicated if learning rates, or the time course of K(+) current block, are graded with stimulus intensity. Synaptic plasticity allows simulated oscillations to synchronize between sites separated by axon conduction delays over 10 msec. Our data suggest that one function of gamma oscillations is to permit synaptic plasticity, which is then expressed in the form of beta oscillations. We propose that the period of gamma oscillations, approximately 25 msec, is "designed" to match the time course of [Ca(2+)](i) fluctuations in dendrites, thus facilitating learning.

Axo-axonal coupling. a novel mechanism for ultrafast neuronal communication

We provide physiological, pharmacological, and structural evidence that axons of hippocampal principal cells are electrically coupled, with prepotentials or spikelets forming the physiological substrate of electrical coupling as observed in cell somata. Antidromic activation of neighboring axons induced somatic spikelet potentials in neurons of CA3, CA1, and dentate gyrus areas of rat hippocampal slices. Somatic invasion by these spikelets was dependent on the activation of fast Na(+) channels in the postjunctional neuron. Antidromically elicited spikelets were suppressed by gap junction blockers and low intracellular pH. Paired axo-somatic and somato-dendritic recordings revealed that the coupling potentials appeared in the axon before invading the soma and the dendrite. Using confocal laser scanning microscopy we found that putative axons of principal cells were dye coupled. Our data thus suggest that hippocampal neurons are coupled by axo-axonal junctions, providing a novel mechanism for very fast electrical communication.

Hospital profitability per hour of operating room time can vary among surgeons

The operating margins (i.e., profits) of hospitals are decreasing. An important aspect of a hospital's finances is the profitability of individual surgical cases, which is measured by contribution margin. We sought to determine the extent to which contribution margin per hour of operating room (OR) time can vary among surgeons. We retrospectively analyzed 2848 elective cases performed by 94 surgeons at the Stanford University School of Medicine. For each case, we subtracted variable costs from the total payment to the hospital to compute contribution margin. We found moderate variability in contribution margin per hour of OR time among surgeons, relative to the variability in contribution margins per OR hour among each surgeon's cases (Cohen's f equaled 0.29, 95% lower confidence interval bound 0.27). Contribution margin per OR hour was negative for 26% of the cases. These results have implications for hospitals for which OR utilization is extensive, and for which elective cases are only scheduled if they can be completed during regularly scheduled hours. To increase or achieve profitability, managers need to increase the hours of lucrative cases, rather than encourage surgeons to do more and more cases. Whether the variability in contribution margin among surgeons should be used to more optimally (profitably) allocate OR time depends on the scheduling objectives of the surgical suite.

Scheduling a delay between different surgeons' cases in the same operating room on the same day using upper prediction bounds for case durations

At some surgical suites, elective cases are only scheduled if they can be completed during regularly scheduled hours. At such a surgical suite, a surgeon may be scheduled to perform one or more cases in an operating room (OR), to be followed by another surgeon who will perform one or more cases. Scheduling a delay between the two surgeons' cases will improve the likelihood that the second surgeon's case(s) will start on time. We show that the mathematics of calculating a scheduled delay between the different surgeons' cases in the same OR on the same day is that of calculating an upper prediction bound for the duration of the second surgeon's case(s). We test an analytical expression for the upper prediction bound for the last one case of the day in an OR, and a Monte Carlo simulation method for the last two cases. We show that these 90% upper prediction bounds are at least as long as the actual durations for 90% +/- 0.2% of single cases and 92% +/- 0.6% of pairs of cases. We conclude that our methodology can be used to calculate an appropriate, and reasonably accurate, scheduled delay between two surgeons' cases in the same OR on the same day.

IMPLICATIONS

We show how to use a statistical analysis of historical case duration data to calculate an appropriate and accurate scheduled delay between two surgeons' cases in the same operating room on the same day.