NorTex 2018 Spring Newsletter

March 28, 2018 • NorTex

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Working Together to Improve Health Outcomes

Spring 2018 2The landscape for providers of continuing medical education (CME) has changed in recent years. Accreditation organizations, regulatory entities, and grantors demand documented reasons for an activity and outcomes reports to prove it made an impact. Many CME providers don’t have access to the expertise or clinical data, making demonstrating need or impact challenging. INCEDO, formerly UNTHSC’s Office of Professional and Continuing Education, collaborates with the NorTex PBRN to help fill these gaps and others related to its projects. NorTex has accessed its network of clinicians to help assess needs for education, conduct educational interventions, and use clinical chart data to measure the outcomes of CME. “A network of clinicians who are interested and agreeable to conducting practice-based research is the brass ring in CME,” said Andrew Crim, INCEDO’s executive director. “NorTex provides a comparative advantage when designing programs, submitting grants, and striving to show higher level outcomes,” he added. An example of the work for which INCEDO and NorTex have collaborated is a recent project about how chronic pain is managed in primary care. The IRB-approved research project was designed to improve the patient experience by testing a standardized, primary care-focused pain management protocol in one UNT Health Science Center clinic and one JPS Health Network clinic. A clinic at each organization also served as a control. One arm of the study recruited patients to wear activity
monitors and agree to share data with researchers as a patient-level assessment to measure improvement in activity, sleep, and heart rate. INCEDO secured funding and JPS’ partnership. NorTex facilitated the IRB applications, managed the patient recruitment for the activity tracker arm, and collected data. Final data for this project are still being analyzed, but preliminary data from the UNTHSC side are encouraging, suggesting improved patient engagement and reduced healthcare utilization by chronic low back pain patients in the UNTHSC clinic that used the pain protocol. The combined efforts on this project was awarded the William Campbell Felch Award for Outstanding Research in Continuing Education by the Alliance for Continuing Education in Health Professions! Practice-based research and continuing education are well-matched. NorTex and INCEDO bring different strengths to a project, increasing the reach and making the likelihood of achieving the desired goal higher.



Atopic Dermatitis: Recognizing a Phobia to Topical Corticosteroids Atopic Dermatitis (AD) is a chronic inflammatory disease affecting up to one in every five children worldwide. It is characterized by a defect in the skin barrier, allowing penetration by allergens, causing a relapsing inflammatory response. Generally, people with atopic dermatitis suffer from dry, sensitive skin with a characteristic intense itch. AD significantly increases health care utilization and costs, with third-party payments for atopic dermatitis in the U.S. totaling more than $5 billion annually in 2017. As many as a quarter of outpatient pediatric primary care office visits are due to skin complaints, and AD is responsible for a substantial number of those. AD is commonly treated with topical corticosteroids; however, patients fear using topical corticosteroids due to the perceived potential for side effects. NorTex, in collaboration with INCEDO, is developing a survey to be distributed among primary care providers throughout Texas
including physicians, nurse practitioners, and physician assistants, to collect information concerning primary care provider’s acknowledgement and recognition of topical corticosteroid phobia. The objective of this survey is to determine if clinicians are aware of their patients’ and their patients’ parents’ fear of using topical corticosteroids to treat atopic dermatitis among children. The survey will be
distributed electronically by INCEDO. This survey is part of a larger project conducted by INCEDO and funded by SANOFI.


Parent’s Perception of Adolescents Health in Association with Child Reported Depression among Mexican American Children 10-14 Years of Age

Spring 2018 3Many parents are unaware of their child’s depression and may not recognize the symptoms, and primary care physicians do not routinely screen for depression in children. Providing a connection between the family, physician, and child to recognize depression is important. One hundred and forty four Mexican American children ages 10-14 and a parent/ legal guardian participated in a cross-sectional study. Child participants completed depression screening using the child report Children’s Depression Inventory. Regression analyses were performed. The dependent variable was child report depression screening (average/lower and high average/ elevated/very elevated), and the primary independent variable was parent reported perception of the child’s health (fair/poor or good/very good/excellent). The adjusted model controlled for family income, marital status of primary care giver, highest grade completed by anyone in the household, child age, and child gender. There were 74 (51.4%) male children, and the mean age was 11.97 (sd=1.45). Thirty (20.80%) children screened high for depression, and parents reported fair/poor health for 11 (7.6%) children. Children were more likely to screen high for depression if their parents reported their health as fair/poor [OR=11.85, (95% CI:2.65-53.05)] or if they were female [OR=3.58, (95% CI:1.37-9.35)] in the adjusted model. Parent’s perception of their child’s health is associated with child self-screening high for depression.

This project was funded by a collaborative intramural project between the UNT Health Science Center and Universidad Autonoma del Estado de Mexico (UAEM).


STARNet (the South Texas Ambulatory Research Network), a practice-based research network, was founded in 1992 by a family physician, Walter Calmbach MD, and has been actively involved in practice-based research since that time. Spring 2018 4STARNet’s mission is “to conduct and disseminate practice-based research that results in new knowledge and improves the health of patients and communities in South Texas.” STARNet is run by a Board of Directors composed of family physicians in private practice who oversee its general direction and research focus. To stay in touch with its member physicians, STARNet hosts twice-yearly “All-Member” meetings, which keep member physicians informed about current and proposed STARNet research projects. STARNet’s current project is funded by the Cancer Prevention Research Institute of Texas (CPRIT). It was developed in response to input from member physicians at one of the semiannual meetings: “How can we do a better job of managing our overweight or obese patients?” STARNet developed a research project focused on using Motivational Interviewing as a better way to help overweight or obese patients lose weight or stabilize their weight. As part of this project, STARNet personnel meet with physicians and practice staff on a regular basis, presenting hour-long sessions on key skills of Motivational Interviewing, such as OARS skills (Open-ended questions, Affirmations, Reflective statements, Summaries), Setting the Agenda, Assessing Importance and Confidence, and Eliciting (and Recognizing!) Change Talk.

To contact STARNet, please call or email Walter Calmbach MD, MPH (ph: 210-358-3200, email: or Johanna Becho MS (ph: 210-358-358-9909; email:


  • Balyakina, E., Fulda, K.G., Franks, S., Cardarelli, K., Hinkle, K. (November 2015). “Association between healthcare provider type and intent to breastfeed among expectant mothers.” 143rd APHA Annual Meeting and Exposition, poster presentation; Chicago, IL.
  • Mallaiah, J., Cross, D., Fulda, K., Espinoza, A., Zhang, J. (April 2016). “Identifying provider and patient barriers to the implementation of MeTree Family Health History Clinical Decision Support (FHH CDS) tools.” 92nd TPHA Annual Education Conference, poster presentation; Galveston, TX.
  • Espinoza, A., Raines-Milenkov, A., Fulda, K., Wilder, M., Lee, M., Salyer-Caldwell, A. (April 2016). “Preconception care and reproductive life planning: engaging primary care providers.” 92nd TPHA Annual Education Conference, poster presentation; Galveston, TX.
  • Namuduri, A., Franks, S.F., Fulda, K., Habiba, N. (April 2016). “Internalizing behaviors in Hispanic boys predict overweight/obese status.” ACOFP 2016 Annual Convention and Scientific Seminars, poster presentation; San Juan, Puerto Rico.
  • Cardarelli, R., Roper, K.L., Studts, C., Fulda, K.G., Holmes, G., Hustedde, C., Crocker, S. (April 2016). “Development and validation of a clinically practical patient assessment: Engagement, Literacy, and Adherence.” Center for Clinical and Translational Science Conference, poster presentation; Lexington, KY.
  • Fernando, S., Gehlsen, J., Fulda, K., Bowman, W. Paul, Habiba, N. (June 2016). “The association between liver enzyome values and risk for type 2 diabetes mellitus among Hispanic children aged 10-14.” Annual Meeting of the Society for Pediatric and Perinatal Epidemiologic Research (SPER), poster presentation; Miami, FL.
  • Fulda, K.G., Franks, S., Fernando, S., Ebert, D. (November 2016). “Relationship between waist to hip circumference and metabolic risk factors in Mexican American adolescents 10-14 years.” North American Primary Care Research Group Annual Meeting, poster presentation; Colorado Springs, Colorado.
  • Baker, L., Franks, S., Fernando, S.I., Habiba, N., Fulda, K. (March 2017). “Are sugar sweetened beverages associated with markers of metabolic syndrome in children?” ACOFP 2017Convention and Scientific Seminars, poster presentation; Kissimmee, FL.
  • Burkholz, J., Fulda, K., Shaffer, M., Franks, S., Fernando, S. (March 2017). “BMI versus waist to hip ratio as a predictor of elevated liver enzymes in Mexican American children.” ACOFP 2017 Convention and Scientific Seminars, poster presentation; Kissimmee, FL.
  • Flores, J., Fulda, K., Franks, S., Shaffer, M., Fernando, S. (March 2017). “Spanish primary language as a risk factor for pre-hypertension in Mexican-American children and adolescents.” ACOFP 2017 Convention and Scientific Seminars, poster presentation; Kissimmee, FL.
  • Santiago, A.M., Fulda, K.G., Franks, S.F., Shaffer, M.D., Fernando, S. (March 2017). “Factors associated with depressive symptoms in Mexican American adolescents.” ACOFP 2017 Convention and Scientific Seminars, poster presentation; Kissimmee, FL.
  • Espinoza, A., Hinojosa, E.J., Aguilar, A., Fulda, K., Espinoza, A., Franks, S. (March 2017). “Exploring the role of protective factors on depressive symptoms among Mexican American adolescents.” 93rd TPHA Annual Education Conference, poster presentation; Fort Worth, TX
  • Fulda, K., Franks, S., Fernando, S., Espinoza, A., Ebert, D. (June 2017). “Changes in risk for type 2 diabetes among Mexican American children.” 2017 NAPCRG PBRN Conference, poster presentation; Bethesda, MD.
  • Fulda, K.G., Franks, S., (November 2017). “Psychosocial factors and intent to breastfeed among pregnant women.” North American Primary Care Research Group Annual Meeting, poster presentation; Montreal, Quebec, Canada. Muzaffar, O., Espinoza, A., Fulda, K., Franks, S. (March 2018). “Parent’s perception of adolescents health in association with child reported depression among Mexican American children 10-14 years of age.” 94th TPHA Annual Education Conference, poster presentation; Waco, TX.



Garth Vaz, M.D. is a family practice physician at The Vaz Clinic, P.A. in Gonzales, Texas. His personal experience with Dyslexia along with his experience diagnosing and dealing with Dyslexia and Learning Disorders has inspired him to help others dealing with similar struggles. Dr. Vaz travels around the world presenting lectures and in-services that not only address Dyslexia, but also deal with multiple learning disabilities and behavioral disorders. Garth Vaz was born in a small village of Westmoreland, Jamaica where he began his pursuit to become a physician at a young age. After overcoming adversity, he immigrated to the US in 1967. While working and living in Brooklyn, New York, he continued his pursuit to become a physician. Dr. Vaz continued his education in Florida, earning the prerequisite credits for medical school, and he was admitted to the University of Florida College of Medicine in 1983, at the age of 36. Conquering his struggle with Dyslexia, he received his license in 1990.Spring 2018 5

Dr. Vaz’s journey to become a physician has been documented in a book written by his brother, “The Doctor He Begged to Be.” In 2009 Dr. Vaz decided to own and operate his own Primary Physician Clinic in Gonzales, TX providing all services including treating ill patients, immunizations, physicals, annual wellness exams, in house labs processed by LabCorp among many other services. In 2010, Dr. Vaz, was voted Best of the Best in the category for Best Doctor by the Gonzales Inquirer, which is judged on a community vote. He is certified as a Long Term AAFP member with the AMA, and he is a member of the ACRP (Association of Clinical Research Professional) and APCR (Association of Physicians in Clinical Research). In 2015, he was awarded a Graduate Certificate for Health Care Leadership and Management for Physicians with the Texas Medical Association by The University of Texas at Dallas. His Primary Care Physician Clinic is also proud to honor our veterans who are enrolled in the Choice program by serving as their primary care physician if they are located within 40 miles of the nearest VA office or they cannot be seen by the VA clinic within 30 days. In 2013, Dr. Vaz also decided to branch out into clinical research. His clinical research experience ranges from phase II to IV trials including anemia due to chronic kidney disease, treatment of acute bacterial skin and skin structure infections, type 2 diabetes mellitus, COPD, asthma, ulcers, heart failure, diabetic kidney disease, community acquired pneumonia and accessing the Sensitivity of Purified Protein Derivative Use in the Elderly. Dr. Vaz is also an advocate for children in his community. He is the cofounder of “Norma’s House” the Gonzales Reginal Children’s Advocacy Center. Furthermore, Dr. Vaz hosted a Radio talk show called “Champion for Children” for over two years. If you are interested in learning more about Dr. Vaz, please visit his website,

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