Latest / UF Health MedEd Cast / BLOCK-SAH & other investigator-initiated research by the Guardians of the Neuroaxis – Leading Neurocritical Care Research in Partnership

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BLOCK-SAH & other investigator-initiated research by the Guardians of the Neuroaxis – Leading Neurocritical Care Research in Partnership · UF Health MedEd Cast

0:03
Melanie Cole, MS (Host): Welcome to UF Health MedEd Cast with
0:05
UF Health Shands Hospital.
0:07
I'm Melanie Cole.
0:08
And we have a panel for you today with two physicians from UF Health to highlight
0:13
BLOCK-SAH, a multi-site research study involving patients with subarachnoid
0:19
hemorrhage, typically due to ruptured aneurysm or trauma, that's evaluating the
0:25
use of specialized nerve blocks to reduce the need for narcotic pain medications,
0:30
as well as other investigator-initiated research by the Guardians of the
0:34
Neuroaxis, leading neurocritical care research in partnership.
0:39
I would also like to mention that we're pleased to point out that the
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2025 Blue Ridge Rankings for NIH funding has recognized that the UF
0:48
Departments of Neurosurgery, Neurology, and Neuroscience Research ranked
0:53
number two nationally in NIH funding.
0:57
Joining me in this panel is Dr.
0:58
Katharina Busl.
1:00
She's a neurologist in the Division of Neurocritical Care in the Department
1:03
of Neurology and the Chief in the Division of Neurocritical Care in
1:07
the Department of Neurology; and Dr.
1:10
Carolina Maciel, she's a neurologist in the Division of Neurocritical
1:14
Care in the Department of Neurology and the Director of Research in
1:18
the Division of Neurocritical Care in the Department of Neurology
1:22
Doctors, thank you so much for joining us today.
1:24
And Dr.
1:25
Busl, I'd like to start with you.
1:27
Can you give us a sense of the vision behind what your team calls the
1:31
Guardians of the Neuroaxis, how that philosophy shapes the neurocritical
1:36
care program at UF Health, and how that idea shapes the culture of
1:41
neurocritical care at UF Health?
1:44
Dr. Katharina Busl:
1:44
I'd be happy to.
1:45
I also will say that the whole spirit of what I'm going to say is really
1:50
meant to be in partnership, and Carolina is actually the Director of the
1:54
NeuroGuardians of our NeuroGuardians Lab.
1:56
So, in essence, what we are noticing is that in an intensive care unit
2:02
where stakes are high, intensity is high, acuity is high, and the model
2:07
is provision in shift work rather than longitudinal continuity of care for the
2:12
reason that we are a high acuity, high intensity intensive care unit, is that
2:17
all of us when in the same boat, and here literally a good boat, which is the boat
2:22
of being able to provide research-guided treatments, research-guided care ideas,
2:29
and improvements in care paradigms, that when we do this together as a whole
2:35
group—and that's why we called us the Guardians—the outcome is going to be
2:40
more cohesive, more palpable perhaps for our patients and more satisfying to us
2:46
because it is not a single individual.
2:49
I think research oftentimes is investigator-driven very much based on
2:54
whoever has an idea and does their thing in their isolated little research world.
3:01
Our approach, again, seeks to approach this very differently through the
3:05
paradigm of provision of care is always a team sport, and we wanted to
3:09
translate that concept directly back to how we run our research enterprise.
3:15
Dr. Carolina Maciel:
3:15
And that's right.
3:16
I want to add to what Katharina is saying is that from the inception of the
3:20
Division of Neurocritical Care at UF, we all came from different institutions,
3:26
and we experienced really state-of-art research, state-of-art clinical care.
3:31
And being trained by leaders of the field and seeing how those very successful
3:37
careers, but with parallel, not necessarily really intertwined across
3:42
the group in a cohesive way to address all the pillars really of what makes a
3:48
program really, really strong—a clinical program, that it is really coupled.
3:54
Those things cannot be really run in parallel: the clinical aspect, the
3:58
research aspect, or the scientific progress, and the education mission.
4:02
So, all those are really together, particularly in neurocritical care.
4:08
Melanie, I wanted to invite you to think that in the day-to-day of our professional
4:14
careers, when we are interfacing with patients, it is a specialty that
4:21
for us, it's another day at work.
4:24
But that individual or that family member, it is experiencing
4:29
a potential emotional turmoil.
4:31
It is either a tragedy or a very serious operation that is required to restore
4:37
function or to improve something or prevent a deficit from happening.
4:42
And the advances of the scientific progress in this field are still lagging
4:48
behind from other areas of medicine.
4:51
So then, being able to actually push the frontiers of knowledge further and add
4:58
answers to the therapeutic arsenal for our patients clinically, this sentiment
5:02
of hope that you can actually achieve something together and make things
5:08
better, it is something that transforms really the atmosphere of the unit from
5:13
a nursing perspective, from a trainee perspective, from a clinician perspective.
5:17
It really doesn't matter which professional that it is over there.
5:20
And without actually bringing together the education piece and then put this
5:25
forward that we are doing this together.
5:28
And one clinical hand does not move forward without the research
5:31
hand, without the education hand.
5:33
So, that is why it is not the Maciel Lab, the Busl Lab.
5:37
It is really the Guardians of Neuroaxis, because everyone in the division plays
5:42
am important role in the cohesive definition of the priorities of
5:47
everything that we are going to pursue.
5:49
And the scientific pursuit is aligned with the clinical and educational pursuit.
5:54
Melanie Cole, MS: That is so interesting.
5:56
And I hear you when you say that research, it was in a silo.
6:00
Now, there's so much information sharing and so many ways to get that information
6:07
and multidisciplinary colleague approach to share with other institutions.
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It really is amazing.
6:13
Now, Dr.
6:14
Maciel, sticking with you for a minute.
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For clinicians who may not be as familiar with the field of neurocritical care and
6:21
how it's evolved in recent years from primarily supportive ICU care, as you were
6:26
saying, some of the most serious cases, to a space where major investigator-initiated
6:32
research is really happening.
6:35
From your perspective, where are we today in terms of translating
6:39
bedside observations into meaningful research questions?
6:44
Dr. Carolina Maciel:
6:44
Something that we are very passionate about, we know nothing about the brain.
6:49
And we will only start learning more about the brain when we are really
6:56
paying attention to what the brain wants in that particular setting.
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So, when you were saying the clinical observations that really
7:03
resonate, because it is by really keenly observing, intentionally so,
7:11
trying to pick it up the signals.
7:13
And the brain is trying to talk, is trying to really express what it is that
7:18
it is required from the critical care.
7:20
So, it is not provision of supportive care.
7:23
It is actually provisioning, like providing the supportive care to target
7:29
the demands of the brain, meaning adjusting the ventilator support, the
7:34
hemodynamic support, the nutritional support, and then picking it up
7:39
those very—like, sometimes we call it the brain whispers, the whispering
7:43
of the brain, that it is demanding more attention towards matching what
7:48
it is the energetic level that the brain needs, that the neurons need
7:52
to recover, and then to prevent from further damage from happening.
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What we know from our field is that we have no control of the
8:02
primary insult, the primary injury.
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And then, we will just support through hoping that the person recovers.
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Now, we know that while we are supporting, a lot of secondary injury
8:15
may happen, and we need to be better at picking it up, those signs of when it
8:20
is happening, and then doing a careful conduction of this orchestra of every
8:27
single player in the unit, in the transdisciplinary care of that patient.
8:33
So, we actually play together the symphony that the brain
8:37
really wants to be able to heal.
8:39
Does that make sense?
8:40
Melanie Cole, MS: Well, it certainly does.
8:42
So then, along those lines, Dr.
8:44
Busl, as neurocritical care sits at the intersection of neurology, neurosurgery,
8:50
critical care, and research, as Dr.
8:53
Maciel was just saying, how has UF Health positioned itself as an
8:58
academic neurocritical care unit that integrates all of these pieces?
9:02
I'd like for you to speak about building that care research
9:06
program and investigator-initiated clinical trials, the BLOCK-SAH
9:11
that I mentioned in the intro.
9:13
Tell us about that.
9:15
Dr. Katharina Busl:
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I think the main piece to understand or stress out that it is taking a lot
9:20
of different pieces and expertise to really provide that cutting-edge piece
9:26
of provision of care and being able to drive the field further through research.
9:31
And that does not happen in small pockets of healthcare, right?
9:35
I think the big piece is obviously our main hospital in Gainesville, which
9:39
is an amazing collection of experts in the various fields that you mentioned,
9:45
neurologists, and specifically our neurology-trained neurocritical care
9:49
group, our colleagues from emergency medicine, neurology critical care, our
9:54
colleagues from anesthesiology that have specialized in neuroanesthesiology
9:58
and pain medicine and then, of course, our neurosurgery colleagues
10:02
with various sub-specializations.
10:04
And among our neurology group, then the more longitudinal colleagues
10:08
that see people when they have healed from the acute stage.
10:11
So in essence, I think for a puzzle to be complete, you need
10:15
many pieces of that puzzle.
10:17
And for complex puzzles, these pieces are more so than for more simpler pictures.
10:24
And the UF system has its flagship hospital that is the main centerpiece of
10:30
a larger puzzle, if that infographical reflection at all resonates.
10:36
Melanie Cole, MS: Yeah, it certainly
10:44
does.
10:44
So, switching gears just a little bit, Dr.
10:45
Maciel, let's talk about subarachnoid hemorrhage.
10:46
And despite advances in aneurysm treatment and ICU management, why does
10:49
this condition remain such a challenge?
10:51
Many people focus on the acute phase, obviously.
10:55
But survivorship after this can be complex.
10:59
Speak about some of the long-term issues patients face that have
11:03
motivated these new research efforts.
11:07
Dr. Carolina Maciel:
11:07
Yeah.
11:07
A lot of the cornerstone for research and scientific progress in
11:12
subarachnoid hemorrhage has been in understanding how to better treat
11:16
the culprit, what causes the bleeding in the brain to happen, and then
11:21
advancing how to treat those aneurysms.
11:24
Oftentimes they are related to aneurysms.
11:27
And, honestly, we are really fortunate to have state-of-the-art treatment
11:32
at University of Florida with every possible new treatment to secure that.
11:37
And then, a lot of the effort also is focused on preventing additional
11:42
brain injury, as we discussed, right?
11:44
A secondary brain injury.
11:46
Throughout the process, the survivorship, and actually it starts even in the ICU
11:52
when the patient is still suffering from the discomfort that this condition
11:57
causes with this worst headache of life.
12:00
And then, after they recover enough to be discharged from the hospital, there
12:05
are several different challenges that they may face in coming back to society.
12:11
As a matter of fact, this is a condition that affect for the
12:15
most part middle-age adults.
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And they are our workforce.
12:19
Oftentimes, those challenges prevent them from really being integrated again
12:24
in the society and actually be back to their functional life and be back to work.
12:28
And those challenges really manifest in sometimes some thinking problems
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like the cognitive aspect, being able to really think clearly and execute
12:39
the thought process appropriately.
12:41
And also, some pain, mood disorder, the subarachnoid hemorrhage, despite
12:47
all the bleeding be reabsorbed and the brain healing in as much as it can.
12:52
You can still have chronic symptoms from it, such as ongoing headaches,
12:58
difficulty thinking, difficulty speaking, difficulty with mobility, tremulousness.
13:05
So, longitudinal follow-up is important.
13:07
And also, neuropsychiatric symptoms, right, with anxiety, depression.
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It is a traumatic event that oftentimes patients and co-survivors also feel
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afraid of return to the activity that they were doing at the onset of the bleeding.
13:22
So, being able to follow those patients and continue to expand the
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breadth of research to address not only what physicians and clinicians
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target as priority, but hearing from patients and survivors and co-survivors
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what additional areas of research are important should be addressed.
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And that is really what motivated us on BLOCK-SUB-ARACH when we have
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all those advances in the management of subarachnoid hemorrhage, but we
13:54
remained really, left with a very scant therapeutic arsenal for addressing
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the headache that it is so prevalent.
14:01
So, we need to continue to partner with patients and survivors to
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hear from them what are the topics of priority for research, so we
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leave really no brain behind.
14:14
We leave really no patient behind in their needs.
14:19
Melanie Cole, MS: Yeah, that's so interesting.
14:21
What an important need that you are both meeting.
14:24
And Dr.
14:25
Busl, as we're talking about the clinical problem that the BLOCK-SAH
14:30
study is designed to address, and we know multi-center trials are complex
14:35
undertakings, how did you build the collaboration and infrastructure
14:39
necessary to launch a national investigator-initiated study?
14:44
If it's described as a patient-centered trial.
14:47
How does the study design reflect those needs and the experiences
14:51
of patients that are recovering from subarachnoid hemorrhage?
14:55
Dr. Katharina Busl:
14:55
There's a lot in that one question, and it's probably many questions.
14:59
So to answer your first question, how did we build the infrastructure?
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I think the biggest part here was that both Carolina and I—and this
15:08
comes back to the philosophy of our Guardians of the Neuroaxis Research
15:12
Lab—is that we are profoundly collaboratively spirited people.
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And we had built relationships for the longest of our careers.
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Looking back really from the beginning, one builds, and we come both from
15:26
different institutions, so the network grew kind of exponentially
15:30
with us leaving those institutions, training in other institutions.
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And in each of those, not leaving everything behind, but having
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left with a network of people.
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So when we had the research question flushed out and we had the trial in
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a state that we were invited by the National Institutes of Health to
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submit for a funding proposal, we could look back on that network that we had
15:53
formed and fairly rapidly establish a consortium of sites based on our
16:00
knowledge and integration within the professional societies, with our own
16:05
collaborations that we had established and, again, maintained over the years.
16:10
And while that still is a huge entertaining, it really also rested
16:14
on personal relationships and knowing of like-minded colleagues that were
16:19
interested in the topic and likewise wanted to move a field forward in
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a very niche aspect that is so much more important for the patient.
16:28
And that leads me to the next part of your question is, when asking patients
16:33
what is important to them during the hospital stay, oftentimes pain comes to
16:38
mind and is one of the very important things that patients and families are
16:43
emotionally really challenged with, because seeing a loved one in pain
16:47
and being miserable is awful and, of course, going through it as the patient
16:52
is awful so the patient-centeredness starts right there with this observation.
16:56
While there is this big discrepancy that what Carolina mentioned earlier,
17:01
the research that have been conducted and has been conducted in that field
17:04
has, by and large, focused on different aspects, very important aspects on
17:10
how do we acknowledge, diagnose, predict that secondary brain injury.
17:15
But in the acute phase, it also has, for the longest of times, left
17:20
out what is important to patients and what are patients and families
17:23
bothered by more palpably and directly.
17:27
So, the patient-centeredness starts right there.
17:29
The second piece is that we did really pay attention to what it is known—although
17:35
a much smaller fraction than many of the numerical values of how this disease
17:41
evolves over time—but paid attention to what it is known about the outcomes
17:45
and the challenges that our survivors face in the realm of cognitive and mood
17:51
dysfunction, depression, anxiety, how to adjust living with this, having gone
17:56
through a very critical and in many times, potentially near-deadly event.
18:02
So, we pulled off of those.
18:04
We also aligned with what is known as the National Institutes of Health
18:08
Common Data Elements to align with other researchers that delve into
18:12
this so that we can have results that are as best as possible comparable.
18:16
And then, of course, we honed in on the aspect that we are studying
18:21
first and foremost, which is the pain aspect, and borrowed a lot of elements
18:26
from pain research, translating them into our neurocritical care
18:30
context, which is a novelty in itself.
18:33
Melanie Cole, MS: Yeah, this is such a fascinating topic.
18:35
And so Dr.
18:36
Maciel, one of the themes, a recurring theme that I'm noticing as we're talking
18:41
here today in your program is that concept of team science and shared leadership.
18:45
What does that collaboration look like across neurology, neurosurgery,
18:49
critical care research teams?
18:51
Tell us about the power of team science and how it works within UF Health.
18:57
Dr. Carolina Maciel:
18:57
The first thing that I want to point out is that resourcefulness
19:02
is what comes to mind.
19:03
It is being attuned to what do we have available to us in terms of expertise,
19:11
in terms of really brain power to make things happen and to innovatively
19:17
address frustrating questions based on the frontiers of knowledge, right?
19:22
So then, what that looks like is that as you could see, if you look at our
19:27
scientific portfolio, you can see all different themes of research.
19:33
It is outcome prediction.
19:35
It is neuromonitoring, so we can actually understand the whispers of the brain.
19:39
It is novel approaches to refractory seizures.
19:43
It is novel approaches to pain as the example of BLOCK-SAH.
19:48
And it is novel approaches to traumatic spinal cord injury.
19:53
So, whatever it is that we face on the day-to-day, as a frustration from this is
20:01
all the knowledge that there is available.
20:03
This is the state-of-the-art, and we have access to everything that it is known
20:07
to benefit, and that is still not enough because the challenge that we are facing
20:14
in our field is that we need to push.
20:17
We need to move the needle further.
20:19
We need to move forward.
20:21
It is really a sentiment of looking around, picking in each other's brains
20:27
with humility, with understanding that there is so much more to get discovered.
20:33
There is so much more to be learned about the brain and then about the recovery.
20:38
And then, looking around and see who is the best person that we
20:42
can partner with for that specific expertise, and we assemble the team.
20:46
And that's why BLOCK-SAH has this partnership of us in neurocritical
20:52
care, anesthesia, and neurosurgery with SPICO, which is another clinical
20:57
trial that we developed together, arising from University of Florida.
21:02
It is a partnership across colleges, not only across department in the
21:06
College of Medicine, but across college with experts in the biomarkers,
21:12
biochemistry, and understanding neuroplasticity and recovery, including
21:18
the neurorehabilitation aspect.
21:20
And the partnership with the expertise here in machine learning
21:25
that our division also has with bioinformatics and the critical
21:29
care artificial intelligence group.
21:32
And this is what it is about.
21:33
It is about acknowledging, staying attuned to all the breadth of
21:39
resources that we have available, and that is the shared leadership.
21:43
Because this is about making progress, scientific progress, that translates into
21:49
meaningful impact in the field, to push it forward so then we are better clinicians.
21:57
And we continue to train leaders of the field.
22:00
And we cannot do that without sharing the goals and then sharing the
22:07
accolades, sharing the accomplishments and sharing the resources.
22:11
And there is no way of doing complex research without team science.
22:17
It truly is an orchestra with many different instruments, and
22:21
they all serve a specific purpose.
22:24
And they are much more simpler and less impactful on their own, but so
22:29
much more rich and impactful together.
22:31
Melanie Cole, MS: Oh, that was beautifully said.
22:34
And really, what an exciting time in your field and what exciting work you're doing.
22:39
I'd love to give you each a chance for a final thought here.
22:41
So Dr.
22:42
Busl, another major goal that we've talked about a little bit is cultivating
22:47
that next generation of clinical scientists and physician scientists.
22:53
So, how are trainees and early career investigators involved in
22:58
these projects beyond BLOCK-SAH?
23:01
Tell us a little bit about how these investigator-initiated projects or
23:05
research directions are emerging from this program and how you're involving
23:10
these early career investigators in them.
23:14
Dr. Katharina Busl:
23:14
We have built our research enterprise on involving learners of all
23:20
levels, and we see ourselves, of course, as lifelong learners too.
23:24
So, that means we have really all stages, both in the clinical as well
23:29
as purely research-oriented scholars as we have named our team members.
23:34
And that starts from undergraduate students, and there is no one that cannot
23:40
contribute in one way or the other.
23:41
I think that is our philosophy as long as there is a will and there
23:45
is the opportunity to join our team.
23:47
And our scholars, again, that spans from undergrad to graduate to postgraduate
23:53
students and even graduated physicians that are laying the foundation to
23:58
become physician in training through residencies and are seeking to acquire
24:04
research-minded skills before they embark on the clinical training side.
24:09
We have included them really in all steps and in all layers in our research programs
24:14
to expose not only them to opportunities to learn in each of those states, but
24:19
then also when they go on to become clinicians and to train in the clinical
24:22
field, to think back and integrate those items from the very beginning.
24:27
And I think not wanting to necessarily speak for Carolina too, although I
24:32
think in aspects we probably share a similarity that for us during our
24:37
training, that was an aspect we had a desire to do, and it was moved to the
24:42
back burner for a variety of reasons, and then we unfolded it later on.
24:46
So, we made a real effort to offer this training before the clinical training
24:53
starts to allow the opportunity to integrate from the very beginning.
24:58
Dr. Carolina Maciel:
24:58
That's right.
24:59
And then, to add to what Katharina is saying is that we are really
25:03
mindful that success looks like in a different way to different people.
25:08
And we really are about being trailblazers in all aspects.
25:14
And innovation comes from these potentially unexplored pathways.
25:19
And the more comprehensive and diverse group that we have from different
25:23
backgrounds, including in level of training and also experiences in
25:28
life prior to really joining and coming at UF, our strength comes from
25:34
having these complementary angles and vantage points that allows us to have
25:40
the complementary skills and growth.
25:43
And then, having this shared growth mindset and the complementary skill
25:48
set, this is what allows us to really propel forward, despite what many will
25:54
say unconventional pathways, right?
25:56
Like, as researchers, our trajectory was different than
26:00
different institutions, right?
26:02
Like, if you think about the Neurocritical Care Division is actually
26:05
completing ten years this year, right?
26:08
As Katharina came to really found the division and create this division.
26:12
So, we are only ten years old, which is really nothing if you think about
26:16
the field of neurocritical care and the tradition of institutions.
26:21
We are able to actually have such momentum for really pushing the needle and moving
26:27
the field forward because of this creative and all-encompassing approach to let's
26:35
explore all the pathways together.
26:37
Let's really stay attuned to all the resources that we have.
26:41
And it is truly about legacy, So, by training the next generation of impactful
26:49
academic neurologists and neuroscientists, it's how we are best positioned to truly
26:54
make an impact on the field, beyond our own discoveries during our lifetime.
26:59
So, it is planting the seed of that dissatisfaction with the status
27:05
quo, that the progress that we are experiencing right now, it's
27:10
excellent, but it can be better.
27:13
And there are many questions left unanswered.
27:16
And for as long as our patients, their families and our team poses or
27:23
ponders with a clinical challenging question, the job is not done.
27:29
And then, the more that we can actually plant that seed, that we need more
27:34
guardians of the neuroaxis everywhere, not only at University of Florida.
27:39
We are best positioned for the true mission, that the patient is really
27:44
the center of everything that we do.
27:47
That is really the purpose.
27:49
That is why we wake up so early in the morning.
27:52
That is why in the middle of the shower, there is that thought process
27:55
of like, "Hmm, I wonder what was happening with that patient how could
28:00
I have done something different?
28:02
How could our team have done something different?"
28:05
It is that unsettledness that really propels us to explore further, go
28:12
deeper, and challenge the status quo.
28:16
Melanie Cole, MS: Wow.
28:17
Thank you so much, both of you, for joining us today.
28:20
That was an incredible episode, and what a great discussion.
28:25
Thank you both for all the great work that you're doing and for joining
28:28
us today and sharing your incredible expertise for other providers.
28:33
To learn more about this and other healthcare topics at UF
28:36
Health Shands Hospital, please visit innovation.ufhealth.org.
28:40
And to listen to more podcasts from our experts, please
28:43
visit ufhealth.org/medmatters.
28:46
That concludes today's episode of UF Health MedEd Cast with
28:50
UF Health Shands Hospital.
28:52
I'm Melanie Cole.