Genetically altered AMPA-type glutamate receptor kinetics in interneurons disrupt long-range synchrony of gamma oscillation

Gamma oscillations synchronized between distant neuronal populations may be critical for binding together brain regions devoted to common processing tasks. Network modeling predicts that such synchrony depends in part on the fast time course of excitatory postsynaptic potentials (EPSPs) in interneurons, and that even moderate slowing of this time course will disrupt synchrony. We generated mice with slowed interneuron EPSPs by gene targeting, in which the gene encoding the 67-kDa form of glutamic acid decarboxylase (GAD67) was altered to drive expression of the alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) glutamate receptor subunit GluR-B. GluR-B is a determinant of the relatively slow EPSPs in excitatory neurons and is normally expressed at low levels in gamma-aminobutyric acid (GABA)ergic interneurons, but at high levels in the GAD-GluR-B mice. In both wild-type and GAD-GluR-B mice, tetanic stimuli evoked gamma oscillations that were indistinguishable in local field potential recordings. Remarkably, however, oscillation synchrony between spatially separated sites was severely disrupted in the mutant, in association with changes in interneuron firing patterns. The congruence between mouse and model suggests that the rapid time course of AMPA receptor-mediated EPSPs in interneurons might serve to allow gamma oscillations to synchronize over distance.

Could plasticity of inhibition pattern pattern generators?

A modeling study shows that inhibitory synapse plasticity, guided by simple activity-dependent rules, can lead to appropriate phase relationships within an oscillating network.

Differential expression of synaptic and nonsynaptic mechanisms underlying stimulus-induced gamma oscillations in vitro

Gamma frequency oscillations occur in hippocampus in vitro after brief tetani delivered to afferent pathways. Previous reports have characterized these oscillations as either (1) trains of GABA(A) inhibitory synaptic events mediated by depolarization of both pyramidal cells and interneurons at least in part mediated by metabotropic glutamate and acetylcholine receptors, or (2) field potential oscillations occurring in the near absence of an inhibitory synaptic oscillation when cells are driven by depolarizing GABA responses and local synchrony is produced by field effects. The aim of this study was to investigate factors involved in the differential expression of these synaptically and nonsynaptically gated oscillations. Field effects were undetectable in control recordings but manifested when slices were perfused with hypo-osmotic solutions or a reduced level of normal perfusate. These manipulations also reduced the amplitude of the train of inhibitory synaptic events associated with an oscillation and enhanced the depolarizing GABA component underlying the post-tetanic depolarization. The resulting field oscillation was still dependent, at least in part, on inhibitory synaptic transmission, but spatiotemporal aspects of the oscillation were severely disrupted. These changes were also accompanied by an increase in estimated [K(+)](o) compared with control. We suggest that nonsynaptic oscillations occur under conditions also associated with epileptiform activity and constitute a phenomenon that is distinct from synaptically gated oscillations. The latter remain a viable model for in vivo oscillations of cognitive relevance.

Synaptic and nonsynaptic contributions to giant ipsps and ectopic spikes induced by 4-aminopyridine in the hippocampus in vitro

Hippocampal slices bathed in 4-aminopyridine (4-AP, < or =200 microM) exhibit 1) spontaneous large inhibitory postsynaptic potentials (IPSPs) in pyramidal cells, which occur without the necessity of fast glutamatergic receptors, and which hence are presumed to arise from coordinated firing in populations of interneurons; 2) spikes of variable amplitude, presumed to be of antidromic origin, in some pyramidal cells during the large IPSP; 3) bursts of action potentials in selected populations of interneurons, occurring independently of fast glutamatergic and of GABA(A) receptors. We have used neuron pairs, and a large network model (3,072 pyramidal cells, 384 interneurons), to examine how these phenomena might be inter-related. Network bursts in electrically coupled interneurons have previously been shown to be possible with dendritic gap junctions, when the dendrites were capable of spike initiation, and when action potentials could cross from cell to cell via gap junctions; recent experimental data showing that dendritic gap junctions between cortical interneurons lead to coupling potentials of only about 0.5 mV argue against this mechanism, however. We now show that axonal gap junctions between interneurons could also lead to network bursts; this concept is consistent with the occurrence of spikelets and partial spikes in at least some interneurons in 4-AP. In our model, spontaneous antidromic action potentials can induce spikelets and action potentials in principal cells during the large IPSP. The probability of observing this type of activity increases significantly when axonal gap junctions also exist between pyramidal cells. Sufficient antidromic activity in the model can lead to epileptiform bursts, independent of alpha-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid (AMPA) and N-methyl-D-aspartate (NMDA) receptors, in some principal cells, preceded by IPSPs and spikelets. The model predicts that gap junction blockers should suppress large IPSPs observed in 4-AP and should also reduce the probability of observing antidromic activity, or bursting, in pyramidal cells. Experiments show that, indeed, the gap junction blocking compound carbenoxolone does suppress spontaneous large IPSCs, occurring in 4-AP plus ionotropic glutamate blockers, together with a GABA(B) receptor blocker; carbenoxolone also suppresses large, fast inward currents, corresponding to ectopic spikes, which occur in 4-AP. Carbenoxolone does not suppress large depolarizing IPSPs induced by tetanic stimulation. We conclude that in 4-AP, axonal gap junctions could, at least in principle, account in part for both the large IPSPs, and for the antidromic activity in pyramidal neurons.

A possible role for gap junctions in generation of very fast EEG oscillations preceding the onset of, and perhaps initiating, seizures

PURPOSE

We propose an experimentally and clinically testable hypothesis, concerning the origin of very fast (> approximately 70 Hz) EEG oscillations that sometimes precede the onset of focal seizures. These oscillations are important, as they may play a causal role in the initiation of seizures.

METHODS

Subdural EEG recordings were obtained from children with focal cortical dysplasias and intractable seizures. Intra- and extracellular recordings were performed in rat hippocampal slices, with induction of population activity, as follows: (a) bath-applied tetramethylamine (an intracellular alkalinizing agent, that opens gap junctions); (b) bath-applied carbachol, a cholinergic agonist; and (c) focal pressure ejection of hypertonic K+ solution. Detailed network simulations were performed, the better to understand the cellular mechanisms underlying oscillations. A major feature of the simulations was inclusion of axon-axon gap junctions between principal neurons, as supported by recent experimental data.

RESULTS

Very fast oscillations were found in children before seizure onset, but also superimposed on bursts during the seizure, and on interictal bursts. In slice experiments, very fast oscillations had previously been seen on interictal-like bursts; we now show such oscillations before, between, and after epileptiform bursts. Very fast oscillations were also seen superimposed on gamma (30-70 Hz) oscillations induced by carbachol or hypertonic K+, and in the latter case, very fast oscillations became continuous when chemical synapses were blocked. Simulations replicate these data, when axonal gap junctions are included.

CONCLUSIONS

Electrical coupling between principal neurons, perhaps via axonal gap junctions, could underlie very fast population oscillations, in seizure-prone brain, but possibly also in normal brain. The anticonvulsant potential of gap-junction blockers such as carbenoxolone, now in clinical use for treatment of ulcer disease, should be considered.

Inhibition-based rhythms: experimental and mathematical observations on network dynamics

An increasingly large body of data exists which demonstrates that oscillations of frequency 12-80 Hz are a consequence of, or are inextricably linked to, the behaviour of inhibitory interneurons in the central nervous system. This frequency range covers the EEG bands beta 1 (12-20 Hz), beta 2 (20-30 Hz) and gamma (30-80 Hz). The pharmacological profile of both spontaneous and sensory-evoked EEG potentials reveals a very strong influence on these rhythms by drugs which have direct effects on GABA(A) receptor-mediated synaptic transmission (general anaesthetics, sedative/hypnotics) or indirect effects on inhibitory neuronal function (opiates, ketamine). In addition, a number of experimental models of, in particular, gamma-frequency oscillations, have revealed both common denominators for oscillation generation and function, and subtle differences in network dynamics between the different frequency ranges. Powerful computer and mathematical modelling techniques based around both clinical and experimental observations have recently provided invaluable insight into the behaviour of large networks of interconnected neurons. In particular, the mechanistic profile of oscillations generated as an emergent property of such networks, and the mathematical derivation of this complex phenomenon have much to contribute to our understanding of how and why neurons oscillate. This review will provide the reader with a brief outline of the basic properties of inhibition-based oscillations in the CNS by combining research from laboratory models, large-scale neuronal network simulations, and mathematical analysis.

The lack of systematic month-to-month variation over one-year periods in ambulatory surgery caseload -application to anesthesia staffing

Anesthesia groups forecast future workload so that staffing and future hiring can be adjusted. Statistical methods have been developed to estimate the number of anesthesia providers needed to minimize labor costs during regularly scheduled hours, second-shifts, and weekends. These methods are simple, in that they assume that, on this medium-range (11-mo) basis, workload varies irregularly around a mean workload. To test whether this assumption is likely to hold for many anesthesia groups nationwide, raw data from the 1994 to 1996 National Survey of Ambulatory Surgery were reanalyzed. To assure that month-to-month systematic variation in workload (e.g., seasonal variation) could be detected if it were present, the average number of myringotomy tubes inserted each day in ambulatory surgery centers of the United States was also examined. The average number of ambulatory surgery cases performed with an anesthesia provider each day in the United States per 10,000 population was found to have not varied systematically month to month on a medium-range (11-mo) basis. In contrast, the average number of tubes inserted each day varied systematically among months for all 26 of the overlapping 11-mo periods in the 36 mo of the survey. These findings suggest that the relatively simple statistical methods that are available to estimate future anesthesia workload will work for many anesthesia groups.

A model of gamma-frequency network oscillations induced in the rat CA3 region by carbachol in vitro

Carbachol (> 20 microM) and kainate (100 nM) induce, in the in vitro CA3 region, synchronized neuronal population oscillations at approximately 40 Hz having distinctive features: (i) the oscillations persist for hours; (ii) interneurons in kainate fire at 5-20 Hz and their firing is tightly locked to field potential maxima (recorded in s. radiatum); (iii) in contrast, pyramidal cells, in both carbachol and kainate, fire at frequencies as low as 2 Hz, and their firing is less tightly locked to field potentials; (iv) the oscillations require GABAA receptors, AMPA receptors and gap junctions. Using a network of 3072 pyramidal cells and 384 interneurons (each multicompartmental and containing a segment of unmyelinated axon), we employed computer simulations to examine conditions under which network oscillations might occur with the experimentally determined properties. We found that such network oscillations could be generated, robustly, when gap junctions were located between pyramidal cell axons, as suggested to occur based on studies of spontaneous high-frequency (> 100 Hz) network oscillations in the in vitro hippocampus. In the model, pyramidal cell somatic firing was not essential for the oscillations. Critical components of the model are (i) the plexus of pyramidal cell axons, randomly and sparsely interconnected by gap junctions; (ii) glutamate synapses onto interneurons; (iii) synaptic inhibition between interneurons and onto pyramidal cell axons and somata; (iv) a sufficiently high rate of spontaneous action potentials generated in pyramidal cell axons. This model explains the dependence of network oscillations on GABA(A) and AMPA receptors, as well as on gap junctions. Besides the existence of axon-axon gap junctions, the model predicts that many of the pyramidal cell action potentials, during sustained gamma oscillations, are initiated in axons.

Statistical method for predicting when patients should be ready on the day of surgery

BACKGROUND

Previously, mathematical theory was developed for determining when a patient should be ready for surgery on the day of surgery. To apply this theory, a method is needed to predict the earliest start time of the case.

METHODS

The authors calculated a time estimate such that the probability is 0.05 that the preceding case in the patient's operating room (OR) will be finished before the patient is ready for surgery. This implies there will be a 5% risk of OR personnel being idle and waiting for the patient. This 0. 05 value was chosen by considering the relative cost valuation of an average patient's time to that of an average surgical team based on national salary data. Case duration data from a surgical services information system were used to test different statistical methods to estimate earliest start times.

RESULTS

Simulations found that 0.05 prediction bounds, calculated assuming case durations followed log-normal distributions, achieved actual risks for the OR staff to wait for patients of 0.050 to 0.053 (SEM = 0.001). Nonparametric prediction bounds performed no better than the parametric method. Having patients ready a fixed number of hours before the scheduled starts of their operations is not reliable. If the preceding case in an OR had been underway for 0.5 to 1.5 h, the parametric 0.05 prediction bounds for the time remaining achieved actual risks for OR staff waiting of 0.055 to 0.058 (SEM = 0.001).

CONCLUSION

The earliest start time of a case can be estimated using the 0.05 prediction bound for the duration of the preceding case. The authors show 0.05 prediction bounds can be estimated accurately assuming that case durations follow log-normal distributions.

Ripple (approximately 200-Hz) oscillations in temporal structures

Spontaneous network oscillations near 200 Hz have been described in the hippocampus and parahippocampal regions of rodents and humans. During the last decade the characteristics and the mechanisms behind these field "ripples" have been studied extensively, mainly in rodents. They occur during rest or slow-wave sleep and provide a very fast, short-lasting (approximately 50 msec) rhythmic and synchronous activation of specific projection cells and interneurons. Ripples are frequently triggered by a massive synaptic activation from the hippocampal CA3 subfield, which is called a sharp wave. Recent evidence suggests that ripples have a specific task in memory processing-namely, that they convey information stored in the hippocampus to the cortex where it can be preserved permanently. Network mechanisms involved in ripple oscillations may be relevant for understanding pathologic synchronization processes in temporal lobe epilepsy.

Neuronal fast oscillations as a target site for psychoactive drugs

Neuronal oscillations within the electroencephalogram beta and gamma bands (15-80 Hz) are associated with intense mental activity and cognitive function in general. Specifically, recent advances have implicated gamma oscillations in the processing of sensory stimuli and demonstrated that synchronous gamma oscillations, appearing concurrently in spatially separate brain regions, can induce beta activity. beta activity generated in this manner represents established synchronous communication between brain regions and is thought to represent a neuronal network correlate of the "binding phenomenon" in cognitive theory. This review will outline the mechanisms of generation of these oscillations at the cellular and network level, and will highlight the effects of drugs that may modify these mechanisms. Possible modification of fast oscillations by disease processes and clinical intervention are discussed.

Sequencing cases in the operating room: predicting whether one surgical case will last longer than another

A microscope will be used for the first case of the day in operating room (OR) 1 and then may be used in the second case of the day by a different surgeon in a different OR, OR 2. Provided that the probability is reasonably high that the first case of the day in OR 2 will last longer than the first case in OR 1, the OR manager can be confident in scheduling the microscope to be used by both surgeons on the same day. The OR manager can use statistical decision theory to sequence cases to decrease the impact of limitations in equipment or personnel on case scheduling. This increases utilization of both the capital equipment and OR time. In this study, we derived equations that can be programmed into a surgical services information system to reliably estimate the probability that one case will have a longer duration than another. We confirmed the accuracy of our method by using actual case duration data.

IMPLICATIONS

Our statistical method uses historical case duration data from an operating room information system to estimate the actual probability to within 1.5% that the second case of a pair will last longer than the first case of a pair.

A model of high-frequency ripples in the hippocampus based on synaptic coupling plus axon-axon gap junctions between pyramidal neurons

So-called 200 Hz ripples occur as transient EEG oscillations superimposed on physiological sharp waves in a number of limbic regions of the rat, either awake or anesthetized. In CA1, ripples have maximum amplitude in stratum pyramidale. Many pyramidal cells fail to fire during a ripple, or fire infrequently, superimposed on the sharp wave-associated depolarization, whereas interneurons can fire at high frequencies, possibly as fast as the ripple itself. Recently, we have predicted that networks of pyramidal cells, interconnected by axon-axon gap junctions and without interconnecting chemical synapses, can generate coherent population oscillations at >100 Hz. Here, we show that such networks, to which interneurons have been added along with chemical synaptic interactions between respective cell types, can generate population ripples superimposed on afferent input-induced intracellular depolarizations. During simulated ripples, interneurons fire at high rates, whereas pyramidal cells fire at lower rates. The model oscillation is generated by the electrically coupled pyramidal cell axons, which then phasically excite interneurons at ripple frequency. The oscillation occurs transiently because rippling can express itself only when axons and cells are sufficiently depolarized. Our model predicts the occurrence of spikelets (fast prepotentials) in some pyramidal cells during sharp waves.

Gamma rhythms and beta rhythms have different synchronization properties

Experimental and modeling efforts suggest that rhythms in the CA1 region of the hippocampus that are in the beta range (12-29 Hz) have a different dynamical structure than that of gamma (30-70 Hz). We use a simplified model to show that the different rhythms employ different dynamical mechanisms to synchronize, based on different ionic currents. The beta frequency is able to synchronize over long conduction delays (corresponding to signals traveling a significant distance in the brain) that apparently cannot be tolerated by gamma rhythms. The synchronization properties are consistent with data suggesting that gamma rhythms are used for relatively local computations whereas beta rhythms are used for higher level interactions involving more distant structures.

Statistical method using operating room information system data to determine anesthetist weekend call requirements

We present a statistical method that uses data from surgical services information systems to determine the minimum number of anesthetists to be scheduled for weekend call in an operating room suite. The staffing coverage is predicted that provides for sufficient anesthetists to cover each hour of a 24-hour weekend period, while satisfying a specified risk for being understaffed. The statistical method incorporates shifts of varying start times and durations, as well as historical weekend operating room caseload data. By using this method to schedule weekend staff, an anesthesia group can assure as few anesthetists are on call as possible, and for as few hours as possible, while maintaining the level of risk of understaffing that the anesthesia group is willing to accept. An anesthesia group also can use the method to calculate its risk of being understaffed in the surgical suite based on its existing weekend staffing plan.

Determining staffing requirements for a second shift of anesthetists by graphical analysis of data from operating room information systems

Some operating room (OR) managers face the dilemma whereby all cases in a surgical suite are not completed during a regularly scheduled (e.g., 8-hour) day. If the anesthesia group at the surgical suite plans for its employed anesthetists to work a fixed number of hours each day, then more than 1 shift of anesthetists may be needed to care for the patients in the ORs. We developed a graphical statistical method that anesthetists and anesthesiologists can use to determine how many anesthesia providers are required on the second shift to minimize labor costs. The method uses data from surgical services information systems or hospital information systems to compensate for seasonality or seasonal variation in the number of ORs running at different times of the day. We also consider application of our method to scheduling surgical nurses with multiple overlapping shifts throughout the day.

Anaesthetic/amnesic agents disrupt beta frequency oscillations associated with potentiation of excitatory synaptic potentials in the rat hippocampal slice

1. Anaesthetic agents produce disruption in cognitive function typified by reductions in sensory perception and memory formation. Oscillations within the EEG gamma and beta bands have been linked to sensory perception and memory and have been shown to be modified by anaesthetic agents. 2. Synchronous gamma oscillations generated by brief tetanic stimulation in two regions of hippocampal area CA1 in slices in vitro were seen to potentiate excitatory synaptic communication between the areas. This synaptic potentiation, was seen to contribute to a transition from gamma frequency (30 - 70 Hz) to beta frequency (12 - 30 Hz) oscillations. 3. Four drugs having anaesthetic/hypnotic and amnesic properties were tested on this synchronous gamma-induced beta oscillation. Thiopental 10 - 200 microM, Diazepam 0.05 - 1.0 microM, Morphine 10 - 200 microM, and Ketamine 10 - 200 microM were all added to the bathing medium. Each drug markedly disrupted the formation of beta oscillations in a manner consistent with their primary modes of action. Thiopental and morphine disrupted synchrony of gamma oscillations and prevented potentiation of recurrent excitatory potentials measured in stratum oriens (fEPSPs). Neither diazepam, nor ketamine produced such marked changes in synchrony at gamma frequencies or reduction in potentiation of fEPSPs. However, each disrupted expression of subsequent beta oscillation via changes in the magnitude of inhibitory network gamma oscillations and the duration and magnitude of tetanus-induced depolarization respectively. 4. The degree of disruption of fEPSP potentiation correlated quantitatively with the degree of disruption in synchrony between sites during gamma oscillations. The data indicate that synchronous gamma-induced beta oscillations represent a mode of expression of excitatory synaptic potentiation in the hippocampus, and that anaesthetic/amnesic agents can disrupt this process markedly.

Which algorithm for scheduling add-on elective cases maximizes operating room utilization? Use of bin packing algorithms and fuzzy constraints in operating room management

BACKGROUND

The algorithm to schedule add-on elective cases that maximizes operating room (OR) suite utilization is unknown. The goal of this study was to use computer simulation to evaluate 10 scheduling algorithms described in the management sciences literature to determine their relative performance at scheduling as many hours of add-on elective cases as possible into open OR time.

METHODS

From a surgical services information system for two separate surgical suites, the authors collected these data: (1) hours of open OR time available for add-on cases in each OR each day and (2) duration of each add-on case. These empirical data were used in computer simulations of case scheduling to compare algorithms appropriate for "variable-sized bin packing with bounded space." "Variable size" refers to differing amounts of open time in each "bin," or OR. The end point of the simulations was OR utilization (time an OR was used divided by the time the OR was available).

RESULTS

Each day there were 0.24 +/- 0.11 and 0.28 +/- 0.23 simulated cases (mean +/- SD) scheduled to each OR in each of the two surgical suites. The algorithm that maximized OR utilization, Best Fit Descending with fuzzy constraints, achieved OR utilizations 4% larger than the algorithm with poorest performance.

CONCLUSIONS

We identified the algorithm for scheduling add-on elective cases that maximizes OR utilization for surgical suites that usually have zero or one add-on elective case in each OR. The ease of implementation of the algorithm, either manually or in an OR information system, needs to be studied.

Forecasting surgical groups' total hours of elective cases for allocation of block time: application of time series analysis to operating room management

BACKGROUND

Allocation of the correct amount of operating room (OR) "block time" can provide surgeons with access to sufficient OR time to complete their elective cases while optimally matching staffing with the elective case workload (to maximize labor productivity). To evaluate how to predict accurately total hours of elective cases performed by a surgical group using data from surgical services information systems, the authors addressed the following questions: (1) How many previous 4-week periods of data should be used to minimize error in forecasting a surgical group's total hours of elective cases? (2) Using the number of 4-week periods from question #1, can we detect trends or correlations between successive periods that could be used to improve forecasting accuracy? (3) How can results from questions #1 and #2 be used to calculate an upper prediction bound (upper limit) for the total hours of elective cases that will be completed in a future period? Prediction bounds can be used to budget staffing accurately.

METHODS

Time series analysis was performed on total hours of elective cases over 39 consecutive 4-week periods from 17 surgical groups.

RESULTS

The average of 12 consecutive periods' total hours of elective cases had an appropriate error profile. The observations within each series of 12 consecutive 4-week periods followed a normal distribution, with each observation of total hours of elective cases not correlated with the subsequent observation.

CONCLUSIONS

The average of the most recent 12 4-week periods can be used to predict surgical groups' future use of block time.

Functionally relevant and functionally disruptive (epileptic) synchronized oscillations in brain slices

Focal seizurelike events can be induced in experimental preparations by means of a number of distinct manipulations that differ in synaptic mechanisms. Nevertheless, the form of the seizurelike events can be explained with common principles, including long-lasting excitation of pyramidal cell dendrites and recurrent excitation between pyramidal cells that provides synchronization. One means of induction of seizurelike events, tetanic stimulation, induces a more physiologic type of activity before seizures are elicited, that is, gamma-frequency (> 20 Hz) oscillations. Such oscillations, called 40-Hz oscillations, are believed to be important for cognition in vivo. Experimental gamma oscillations depend critically on synaptic inhibition between interneurons, from interneurons to pyramidal cells, and on a tonic drive to pyramidal cells and interneurons by metabotropic glutamate receptors. The function of gamma oscillations appears to be imposition of a precise temporal structure on the firing patterns of pyramidal cells while still allowing the pyramidal cells to influence each other and be influenced by afferents selectively. We suggest that a relative loss of synaptic inhibition, occurring by any of a number of mechanisms, prevents the occurrence of gamma activity, allows recurrent pyramidal cell-pyramidal cell excitation to predominate, and thereby allows neuronal networks to generate functionally disruptive seizures.

High-frequency population oscillations are predicted to occur in hippocampal pyramidal neuronal networks interconnected by axoaxonal gap junctions

In hippocampal slices, high-frequency (125-333 Hz) synchronized oscillations have been shown to occur amongst populations of pyramidal neurons, in a manner that is independent of chemical synaptic transmission, but which is dependent upon gap junctions. At the intracellular level, high-frequency oscillations are associated with full-sized action potentials and with fast prepotentials. Using simulations of two pyramidal neurons, we previously argued that the submillisecond synchrony, and the rapid time-course of fast prepotentials, could be explained, in principle, if the requisite gap junctions were located between pyramidal cell axons. Here, we use network simulations (3072 pyramidal cells) to explore further the hypothesis that gap junctions occur between axons and could explain high-frequency oscillations. We show that, in randomly connected networks with an average of two gap junctions per cell, or less, synchronized network bursts can arise without chemical synapses, with frequencies in the experimentally observed range (spectral peaks 125-182 Hz). These bursts are associated with fast prepotentials (or partial spikes and spikelets) as observed in physiological recordings. The critical assumptions we must make for the oscillations to occur are: (i) there is a background of ectopic axonal spikes, which can occur at low frequency (one event per 25 s per axon); (ii) the gap junction resistance is small enough that a spike in one axon can induce a spike in the coupled axon at short latency (in the model, a resistance of 273 M omega works, with an associated latency of 0.25 ms). We predict that axoaxonal gap junctions, in combination with recurrent excitatory synapses, can induce the occurrence of high-frequency population spikes superimposed on epileptiform field potentials.

An operating room scheduling strategy to maximize the use of operating room block time: computer simulation of patient scheduling and survey of patients' preferences for surgical waiting time

Determining the appropriate amount of block time to allocate to surgeons and selecting the days on which to schedule elective cases can maximize operating room (OR) use. We used computer simulation to model OR scheduling. Inputs in the computer model included different methods to determine when a patient will have surgery (on-line bin-packing algorithms), case durations, lengths of time patients wait for surgery (2 wk is the median longest length of time that the outpatients [n = 367] surveyed considered acceptable), hours of block time each day, and number of blocks each week. For block time to be allocated to maximize OR utilization, two parameters must be specified: the method used to decide on what day a patient will have surgery and the average length of time patients wait to have surgery. OR utilization depends greatly on, and increases as, the average length of time patients wait for surgery increases.

IMPLICATIONS

Operating room utilization can be maximized by allocating block time for the elective cases based on expected total hours of elective cases, scheduling patients into the first available date provided open block time is available within 4 wk, and otherwise scheduling patients in "overflow" time outside of the block time.

Optimal sequencing of urgent surgical cases. Scheduling cases using operating room information systems

Optimal sequencing of urgent cases (i.e., selecting which urgent case should be performed first and which second) may enhance patient safety, increase patient satisfaction with timeliness of surgery, and minimize surgeons' complaints. Before determining the optimal sequence of urgent cases, an operating room (OR) suite must identify the primary scheduling objective to be satisfied when prioritizing pending urgent cases. These scheduling objectives may include: 1) perform the cases in the sequence that minimizes the average length of time each surgeon and patient waits; 2) perform the cases in the order that they were submitted; or 3) perform the cases based on medical priority, as prioritized by an OR director, or surgeons discussing the cases among themselves. We provide mathematical structure which can be used to program a computerized surgical services information system to assist in optimizing the sequence of urgent cases. We use an example to illustrate that the optimal sequence varies depending on the scheduling objective chosen.