Academic Journal
Correlation between acne and insulin resistance; experience from central India
| Title: | Correlation between acne and insulin resistance; experience from central India |
|---|---|
| Authors: | Prachi R Srivastava, Jaideep Khare, Animesh Saxena, Sushil Jindal |
| Source: | Journal of Family Medicine and Primary Care, Vol 13, Iss 2, Pp 723-725 (2024) |
| Publisher Information: | Wolters Kluwer Medknow Publications, 2024. |
| Publication Year: | 2024 |
| Collection: | LCC:Medicine |
| Subject Terms: | acne, acne grades, homa ir, insulin resistance, metabolic syndrome, Medicine |
| More Details: | Introduction: Acne is a common dermatological condition primarily seen in teenage and adolescent patients and is a major concern for cosmological issues. Along with environmental factors, the proliferation of basal keratinocytes in the sebaceous-pilosebaceous unit, abnormal desquamation of follicular corneocytes, and metabolic abnormalities play a significant role in the pathogenesis of acne development. Aim: To study the causal relation between acne vulgaris and insulin resistance by calculating Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and identify the relation between insulin resistance and the severity of acne. Materials and Methods: This was a retrospective study, where the data of patients with persistent Acne Vulgaris who were referred to the Endocrine department for evaluation of the hormonal and metabolic causes for acne vulgaris were analysed. The patient's clinical records were evaluated in whom there was no significant hormonal or metabolic abnormality identified known to cause persistent acne were included after proper consent and HOMA-IR was calculated. Results: Of several patients with persistent acne, 150 patients were included in our study with the male-to-female ratio was 23:27. The mean age of patients was 33.2 years. The mean HOMA-IR in our acne patients was 1.62 ranging from 0.9-3.7. Sixty four (42.67%) patients had HOMA-IR more than 2.0, thereby suggesting insulin resistance. Conclusion: Our study suggests the prevalence of insulin resistance in 42.67% of patients with acne, thereby providing the possibility of use of insulin modifiers as an adjunct acne treatment and stratifying the possible risk of metabolic syndrome in patients with acne. Also recommended is the control of dietary factors and lifestyle modification for the management of acne with insulin resistance. |
| Document Type: | article |
| File Description: | electronic resource |
| Language: | English |
| ISSN: | 2249-4863 |
| Relation: | http://www.jfmpc.com/article.asp?issn=2249-4863;year=2024;volume=13;issue=2;spage=723;epage=725;aulast=Srivastava; https://doaj.org/toc/2249-4863 |
| DOI: | 10.4103/jfmpc.jfmpc_1232_23 |
| Access URL: | https://doaj.org/article/81e714735fb74c90a213c4d6ab335813 |
| Accession Number: | edsdoj.81e714735fb74c90a213c4d6ab335813 |
| Database: | Directory of Open Access Journals |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHjPtM4BHU3ZchRwgzYmadcigk49r9CVlbU7V5F6lgH7WwGlVVz4LIkKxRwkqPtbMUFNAAAA4jCB3wYJKoZIhvcNAQcGoIHRMIHOAgEAMIHIBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDFn1pDOFdv_s8iQeOwIBEICBmv9V3Z8hiXP7_OjKp7vkeu_AjyZbzuJRe1GVWH0UTwEssx-dIfTXJZR7PLJNkhiXjix9MVcZhoJbapQX4ol7Zn5hxWgIcAgufeW_MzPzdvz7HFsZssffuH8UEtTM7O8lW5u4qH6vktw-fCC5GlAhf1BarpVFdOi70z8szStkDU-8vrN4B03imwPoz-VDs-VHD0bvnguHHo_g-Nk= Text: Availability: 1 Value: <anid>AN0176413001;[fnn4]01feb.24;2024Apr05.08:11;v2.2.500</anid> <title id="AN0176413001-1">Correlation between acne and insulin resistance; experience from central India </title> <p>Introduction: Acne is a common dermatological condition primarily seen in teenage and adolescent patients and is a major concern for cosmological issues. Along with environmental factors, the proliferation of basal keratinocytes in the sebaceous-pilosebaceous unit, abnormal desquamation of follicular corneocytes, and metabolic abnormalities play a significant role in the pathogenesis of acne development. Aim: To study the causal relation between acne vulgaris and insulin resistance by calculating Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and identify the relation between insulin resistance and the severity of acne. Materials and Methods: This was a retrospective study, where the data of patients with persistent Acne Vulgaris who were referred to the Endocrine department for evaluation of the hormonal and metabolic causes for acne vulgaris were analysed. The patient's clinical records were evaluated in whom there was no significant hormonal or metabolic abnormality identified known to cause persistent acne were included after proper consent and HOMA-IR was calculated. Results: Of several patients with persistent acne, 150 patients were included in our study with the male-to-female ratio was 23:27. The mean age of patients was 33.2 years. The mean HOMA-IR in our acne patients was 1.62 ranging from 0.9-3.7. Sixty four (42.67%) patients had HOMA-IR more than 2.0, thereby suggesting insulin resistance. Conclusion: Our study suggests the prevalence of insulin resistance in 42.67% of patients with acne, thereby providing the possibility of use of insulin modifiers as an adjunct acne treatment and stratifying the possible risk of metabolic syndrome in patients with acne. Also recommended is the control of dietary factors and lifestyle modification for the management of acne with insulin resistance.</p> <p>Keywords: Acne; acne grades; HOMA IR; insulin resistance; metabolic syndrome</p> <p>Introduction</p> <p>Acne is a common dermatological condition and is a major concern for cosmological issues. Acne is estimated to affect 9.4% of the general population, making it the eighth most prevalent disease globally.[[<reflink idref="bib1" id="ref1">1</reflink>]] Also, acne vulgaris is one of the most common dermatological disorders with a teenage prevalence of 85%-90% and is thus routinely encountered by primary care physicians. Although usually easily managed, there is a rising number of patients who do not easily respond to therapy or seem resistant to therapy as along with environmental factors, proliferation of basal keratinocytes in the sebaceous-pilosebaceous unit and abnormal desquamation of follicular corneocytes, and metabolic abnormalities play a significant role in pathogenesis of acne.[[<reflink idref="bib2" id="ref2">2</reflink>]] This is also supported by the finding that the prevalence of both metabolic syndrome and acne have increased in recent past in general population.[[<reflink idref="bib3" id="ref3">3</reflink>]] Seema<emph> et al.</emph> have also reported the increase in childhood and teenage obesity even in the developing and third-world countries which can be a possible metabolic abnormality for the increased prevalence of acne among teenagers.[[<reflink idref="bib4" id="ref4">4</reflink>]]</p> <p>We, therefore, conducted a retrospective study to identify the correlation between acne and insulin resistance and correlate the grade of acne with insulin resistance. Insulin resistance was defined if Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) was more than 2 which is calculated from fasting insulin and fasting blood glucose levels.[[<reflink idref="bib5" id="ref5">5</reflink>]]</p> <p>Materials and Methods</p> <p>This was a retrospective cohort study carried out jointly at Endocrine and Dermatology departments and enrolled patients who visited between 01/07/2021 and 01/07/2022. A total of 450 patients with persistent acne were referred to the Endocrine department by the Dermatology department for evaluation of the hormonal and metabolic causes of acne vulgaris. Of 450 patients, 150 patients were included in the study who met inclusion and exclusion criteria after going through extensive clinical records.</p> <p>The inclusion criteria for patients included (<reflink idref="bib1" id="ref6">1</reflink>) adults aged between 18 and 65 years presenting with complaints of persistent acne and (<reflink idref="bib2" id="ref7">2</reflink>) those willing to participate in the study.</p> <p>Exclusion criteria included (<reflink idref="bib1" id="ref8">1</reflink>) sick patients; (<reflink idref="bib2" id="ref9">2</reflink>) diagnosed with diabetes and on treatment for same; (<reflink idref="bib3" id="ref10">3</reflink>) underwent weight reduction treatment in the past; (<reflink idref="bib4" id="ref11">4</reflink>) pregnancy; (<reflink idref="bib5" id="ref12">5</reflink>) on any medications known to affect insulin metabolism including topical steroids or any hormonal treatment for any reason in the previous 1 month; (<reflink idref="bib6" id="ref13">6</reflink>) identified with significant hormonal or metabolic abnormalities on clinical records known to cause persistent acne-like polycystic ovarian syndrome, hyperandrogenism, hyperprolactinemia, and hypercortisolemia; or (<reflink idref="bib5" id="ref14">5</reflink>) not willing to participate in the study.</p> <p>Of 150 patients included in the study, the grading of acne according to the Global Acne Grading System was recorded from clinical records.[[<reflink idref="bib5" id="ref15">5</reflink>]] Along with grading other signs of insulin resistance like <emph>Acanthosis nigricans</emph>, skin tags, body mass index, and waist circumference along with its management modalities and other comorbid conditions were recorded.</p> <p>Laboratory parameters recorded included fasting plasma glucose (FPG) and fasting insulin and HOMA-IR was calculated and correlated with the acne and its severity grade as estimated by the acne scoring system.[[<reflink idref="bib6" id="ref16">6</reflink>]]</p> <p>Results</p> <p>The mean age of our patients was 33.2 years. The male-to-female ratio was 69:81. The baseline characteristics are described in [Table 1]. Seventy one (47.33%) patients had acanthosis nigricans, while 37 (24.67%) had skin tags. The mean body mass index of male patients was 28.11 ± 7.9 kg/m<sups>2</sups> and of the female patient was 27.33 ± 7.33 kg/m<sups>2</sups>.{Table 1}</p> <p>Mean FPG levels were 91 mg/dL, ranging from 69 to 121 mg/dL. Sixteen (10.67%) had FBS more than 100 mg/dL suggesting impaired FPG levels as per American Diabetes Association recommendations. Mean fasting insulin levels were 7.2 mIU/L, ranging from 0.9-29 mIU/L.</p> <p>The mean HOMA-IR in our acne patients is 1.62 ranging from 0.9 to 3.7. Sixty four (42.67%) patients had HOMA-IR more than 2.0 suggesting insulin resistance.</p> <p>According to the Global Acne Grading System, 21 males had grade 1 acne vulgaris, 14 had grade 2, 15 had grade 3, and 19 had grade 4. Of the females, 12 patients had grade 1 acne vulgaris, 49 had grade 2, 15 had grade 3, and 5 had grade 4.</p> <p>In our study, we did not identify a significant correlation between the grade of acne and insulin resistance details of which are described in [Table 2].{Table 2}</p> <p>Discussion</p> <p>Acne is a very common dermatological condition and has a severe psychological impact.[[<reflink idref="bib7" id="ref17">7</reflink>]] The prevalence of patients presenting with complaint of acne has increased in the recent past, which may be because of an actual increase or increased awareness. The prevalence of metabolic syndrome and its components has also increased in the recent past.[[<reflink idref="bib3" id="ref18">3</reflink>]],[[<reflink idref="bib4" id="ref19">4</reflink>]] Studies suggest that along with environmental factors, metabolic abnormalities play a significant role in the pathogenesis of acne development. Other dermatological conditions like psoriasis have also been reported to have an association with metabolic syndrome and control of those parameters has resulted in the betterment of the cutaneous condition.[[<reflink idref="bib8" id="ref20">8</reflink>]] Increased incidence of acne and metabolic syndrome may be inter-related; thus, we conducted a study to identify the correlation between acne and insulin resistance, a marker for metabolic syndrome, and correlate the grade of acne with insulin resistance.</p> <p>In our study, 10.67% patients had impaired FPG levels, while 42.67% patients with acne have HOMA-IR of more than 2.0 suggesting insulin resistance. Thus, our patients with acne in significant numbers had insulin resistance.</p> <p>Our finding was concordant with findings of study by Singh M<emph> et al</emph>. who found statistically significant insulin resistance was present in acne patients and suggested that with conventional treatment of acne, anti-insulin drugs may be used as an adjunctive to treat moderate and severe acne vulgaris.[[<reflink idref="bib9" id="ref21">9</reflink>]]</p> <p>Similarly, Anderson<emph> et al</emph>.[[<reflink idref="bib10" id="ref22">10</reflink>]] and by Adebamowo<emph> et al</emph>.[[<reflink idref="bib11" id="ref23">11</reflink>]] demonstrated that hyperinsulinemia induced by giving an increasing amount of chocolates day by day to the patients resulted in the flaring of acne. Also, Kartal<emph> et al</emph>.[[<reflink idref="bib12" id="ref24">12</reflink>]] did a study where they enrolled only female patients with acne and found a positive relationship between female acne and insulin resistance.</p> <p>However, Munichandrappa<emph> et al</emph>.[[<reflink idref="bib13" id="ref25">13</reflink>]] in their study did not find any significant correlation between acne and insulin resistance in Indian population, which is nonconcordant with our findings and the possible reasons for this can be the small population size with majority of patients with mild category of acne were included in their study, while in our study, we have taken patients having all grades of acne vulgaris.</p> <p>As the incidence of adult-onset acne is at an all-time high, our study sheds light on IR as the possible associated factor in the vast majority of cases. Our study gives a physician an area to explore to treat acne better and also diagnose metabolic disorders at an earlier stage. Our study brings to light the correlation of insulin resistance with acne and also explains why a lot of patients benefit from medications used for IR in treating acne better. Also, a lot of patients relapse after standard therapies for acne and IR could be a possible explanation. Thus, our study will be helpful not only to dermatologists but also physicians to diagnose possible cause-associated factors of acne and treat it better.</p> <p>Conclusion</p> <p>Acne is a very common dermatological condition which severely affects the patients. Our study suggests a significant relation between acne and insulin resistance and opens the possibility of the use of insulin resistance modifiers as an adjunct to acne treatment. Also, these findings suggest the risk of metabolic syndrome in patients with acne; thus, these patients should be stratified for a possible risk of metabolic syndrome and be advised for healthy life style modification for its prevention.</p> <p>Limitation of study</p> <p>Sample bias as patients are from one center and being retrospective study data of many possible patients not included because of paucity in clinical records are possible limitation for study. Authors have no conflict of interest to declare.</p> <p>Financial support and sponsorship</p> <p>Nil.</p> <p>Conflicts of interest</p> <p>There are no conflicts of interest.</p> <ref id="AN0176413001-2"> <title> REFERENCES </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> Tan JK, Bhate K. A global perspective on the epidemiology of acne. Br J Dermatol 2015;172(Suppl 1):3-12. doi: 10.1111/bjd. 13462.</bibtext> </blist> <blist> <bibl id="bib2" idref="ref2" type="bt">2</bibl> <bibtext> Nickles MA, Sharma D, Tsoukas MM, Ashack KA. Acne and insulin resistance: A systematic review and meta-analysis. J Am Acad Dermatol 2022;87:687-8. doi: 10.1016/j.jaad. 2021.12.033.</bibtext> </blist> <blist> <bibl id="bib3" idref="ref3" type="bt">3</bibl> <bibtext> Krishnamoorthy Y, Rajaa S, Murali S, Rehman T, Sahoo J, Kar SS. Prevalence of metabolic syndrome among adult population in India: A systematic review and meta-analysis. PLoS One 2020;15:e0240971.</bibtext> </blist> <blist> <bibl id="bib4" idref="ref4" type="bt">4</bibl> <bibtext> Seema S, Rohilla KK, Kalyani VC, Babbar P. Prevalence and contributing factors for adolescent obesity in present era: Cross-sectional study. J Family Med Prim Care 2021;10:1890-4.</bibtext> </blist> <blist> <bibl id="bib5" idref="ref5" type="bt">5</bibl> <bibtext> Marbaniang I, Sangle S, Salvi S, Kulkarni V, Shere D, Deshpande P, et al. High prevalence of insulin resistance and occurrence prior to hyperinsulinemia threshold among people living with HIV in Pune, India. Diabetes Metab Syndr 2019;13:1813-9. doi: 10.1016/j.dsx. 2019.04.009.</bibtext> </blist> <blist> <bibl id="bib6" idref="ref13" type="bt">6</bibl> <bibtext> Adityan B, Kumari R, Thappa DM. Scoring systems in acne vulgaris. Indian J Dermatol Venereol Leprol 2009;75:323-6.</bibtext> </blist> <blist> <bibl id="bib7" idref="ref17" type="bt">7</bibl> <bibtext> Tan JK. Psychosocial impact of acne vulgaris: Evaluating the evidence. Skin Therapy Lett 2004;9:1-3, 9.</bibtext> </blist> <blist> <bibl id="bib8" idref="ref20" type="bt">8</bibl> <bibtext> Nisa N, Qazi MA. Prevalence of metabolic syndrome in patients with psoriasis. Indian J Dermatol Venereol Leprol 2010;76:662-5.</bibtext> </blist> <blist> <bibl id="bib9" idref="ref21" type="bt">9</bibl> <bibtext> Singh M, Shri D. Insulin resistance in moderate to severe acne vulgaris. Indian J Dermatol 2022;67:205. doi: 10.4103/ijd.ijd_396_21.</bibtext> </blist> <blist> <bibtext> Anderson PC. Foods as the cause of acne. Am Fam Physician 1971;3:102-3.</bibtext> </blist> <blist> <bibtext> Adebamowo CA, Spiegelman D, Berkey CS, Danby FW, Rockett HH, Colditz GA, et al. Milk consumption and acne in adolescent girls. Dermatol Online J 2006;12:1.</bibtext> </blist> <blist> <bibtext> Kartal D, Yildiz H, Ertas R, Borlu M, Utas S. Association between isolated female acne and insulin resistance: A prospective study. G Ital Dermatol Venereol 2016;151:353-7.</bibtext> </blist> <blist> <bibtext> Munichandrappa P, Manjunath KG, Kiran C, Variyar A. A comparative study of insulin resistance in acne vulgaris. Int J Res Dermatol 2017;3:403-6.</bibtext> </blist> </ref> <aug> <p>By Prachi Srivastava; Jaideep Khare; Animesh Saxena and Sushil Jindal</p> <p>Reported by Author; Author; Author; Author</p> </aug> <nolink nlid="nl1" bibid="bib10" firstref="ref22"></nolink> <nolink nlid="nl2" bibid="bib11" firstref="ref23"></nolink> <nolink nlid="nl3" bibid="bib12" firstref="ref24"></nolink> <nolink nlid="nl4" bibid="bib13" firstref="ref25"></nolink> CustomLinks: – Url: https://resolver.ebsco.com/c/xy5jbn/result?sid=EBSCO:edsdoj&genre=article&issn=22494863&ISBN=&volume=13&issue=2&date=20240101&spage=723&pages=723-725&title=Journal of Family Medicine and Primary Care&atitle=Correlation%20between%20acne%20and%20insulin%20resistance%3B%20experience%20from%20central%20India&aulast=Prachi%20R%20Srivastava&id=DOI:10.4103/jfmpc.jfmpc_1232_23 Name: Full Text Finder (for New FTF UI) (s8985755) Category: fullText Text: Find It @ SCU Libraries MouseOverText: Find It @ SCU Libraries – Url: https://doaj.org/article/81e714735fb74c90a213c4d6ab335813 Name: EDS - DOAJ (s8985755) Category: fullText Text: View record from DOAJ MouseOverText: View record from DOAJ |
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| Items | – Name: Title Label: Title Group: Ti Data: Correlation between acne and insulin resistance; experience from central India – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Prachi+R+Srivastava%22">Prachi R Srivastava</searchLink><br /><searchLink fieldCode="AR" term="%22Jaideep+Khare%22">Jaideep Khare</searchLink><br /><searchLink fieldCode="AR" term="%22Animesh+Saxena%22">Animesh Saxena</searchLink><br /><searchLink fieldCode="AR" term="%22Sushil+Jindal%22">Sushil Jindal</searchLink> – Name: TitleSource Label: Source Group: Src Data: Journal of Family Medicine and Primary Care, Vol 13, Iss 2, Pp 723-725 (2024) – Name: Publisher Label: Publisher Information Group: PubInfo Data: Wolters Kluwer Medknow Publications, 2024. – Name: DatePubCY Label: Publication Year Group: Date Data: 2024 – Name: Subset Label: Collection Group: HoldingsInfo Data: LCC:Medicine – Name: Subject Label: Subject Terms Group: Su Data: <searchLink fieldCode="DE" term="%22acne%22">acne</searchLink><br /><searchLink fieldCode="DE" term="%22acne+grades%22">acne grades</searchLink><br /><searchLink fieldCode="DE" term="%22homa+ir%22">homa ir</searchLink><br /><searchLink fieldCode="DE" term="%22insulin+resistance%22">insulin resistance</searchLink><br /><searchLink fieldCode="DE" term="%22metabolic+syndrome%22">metabolic syndrome</searchLink><br /><searchLink fieldCode="DE" term="%22Medicine%22">Medicine</searchLink> – Name: Abstract Label: Description Group: Ab Data: Introduction: Acne is a common dermatological condition primarily seen in teenage and adolescent patients and is a major concern for cosmological issues. Along with environmental factors, the proliferation of basal keratinocytes in the sebaceous-pilosebaceous unit, abnormal desquamation of follicular corneocytes, and metabolic abnormalities play a significant role in the pathogenesis of acne development. Aim: To study the causal relation between acne vulgaris and insulin resistance by calculating Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) and identify the relation between insulin resistance and the severity of acne. Materials and Methods: This was a retrospective study, where the data of patients with persistent Acne Vulgaris who were referred to the Endocrine department for evaluation of the hormonal and metabolic causes for acne vulgaris were analysed. The patient's clinical records were evaluated in whom there was no significant hormonal or metabolic abnormality identified known to cause persistent acne were included after proper consent and HOMA-IR was calculated. Results: Of several patients with persistent acne, 150 patients were included in our study with the male-to-female ratio was 23:27. The mean age of patients was 33.2 years. The mean HOMA-IR in our acne patients was 1.62 ranging from 0.9-3.7. Sixty four (42.67%) patients had HOMA-IR more than 2.0, thereby suggesting insulin resistance. Conclusion: Our study suggests the prevalence of insulin resistance in 42.67% of patients with acne, thereby providing the possibility of use of insulin modifiers as an adjunct acne treatment and stratifying the possible risk of metabolic syndrome in patients with acne. Also recommended is the control of dietary factors and lifestyle modification for the management of acne with insulin resistance. – Name: TypeDocument Label: Document Type Group: TypDoc Data: article – Name: Format Label: File Description Group: SrcInfo Data: electronic resource – Name: Language Label: Language Group: Lang Data: English – Name: ISSN Label: ISSN Group: ISSN Data: 2249-4863 – Name: NoteTitleSource Label: Relation Group: SrcInfo Data: http://www.jfmpc.com/article.asp?issn=2249-4863;year=2024;volume=13;issue=2;spage=723;epage=725;aulast=Srivastava; https://doaj.org/toc/2249-4863 – Name: DOI Label: DOI Group: ID Data: 10.4103/jfmpc.jfmpc_1232_23 – Name: URL Label: Access URL Group: URL Data: <link linkTarget="URL" linkTerm="https://doaj.org/article/81e714735fb74c90a213c4d6ab335813" linkWindow="_blank">https://doaj.org/article/81e714735fb74c90a213c4d6ab335813</link> – Name: AN Label: Accession Number Group: ID Data: edsdoj.81e714735fb74c90a213c4d6ab335813 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.4103/jfmpc.jfmpc_1232_23 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 3 StartPage: 723 Subjects: – SubjectFull: acne Type: general – SubjectFull: acne grades Type: general – SubjectFull: homa ir Type: general – SubjectFull: insulin resistance Type: general – SubjectFull: metabolic syndrome Type: general – SubjectFull: Medicine Type: general Titles: – TitleFull: Correlation between acne and insulin resistance; experience from central India Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Prachi R Srivastava – PersonEntity: Name: NameFull: Jaideep Khare – PersonEntity: Name: NameFull: Animesh Saxena – PersonEntity: Name: NameFull: Sushil Jindal IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 01 Type: published Y: 2024 Identifiers: – Type: issn-print Value: 22494863 Numbering: – Type: volume Value: 13 – Type: issue Value: 2 Titles: – TitleFull: Journal of Family Medicine and Primary Care Type: main |
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