Vitamin D Profile and Disease Activity of Juvenile Idiopathic Arthritis (JIA) Dur- ing Pandemic Covid-19

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2022, Vol. 12, No. 2, 191 – 198 http://dx.doi.org/10.11594/jtls.12.02.05

How to cite:

Research Article

Vitamin D Profile and Disease Activity of Juvenile Idiopathic Arthritis (JIA) Dur- ing Pandemic Covid-19

Desy Wulandari *^{1, 2}, Wisnu Barlianto ^{1, 2}, Tita Luthfia Sari ^{1, 2}

1 Pediatric Department, Faculty of Medicine, Universitas Brawijaya, Malang 65145, Indonesia

2 Pediatric Department, dr. Saiful Anwar Hospital, Malang 65112, Indonesia

Article history:

Submission December 2021 Revised December 2021 Accepted March 2022

ABSTRACT

Vitamin D (25-Hydroxyvitamin D3 [25(OH)D3]) has an important role in the immune system. This study aimed to assess the relationship between 25-Hydroxyvitamin D3 and disease activity in Indonesian children with Juvenile Idiopathic Arthritis (JIA) during pandemic Covid-19. A 12-week randomized control trial was undertaken at Saiful Anwar Hospital between June and September 2021. JIA patients are divided into two groups. The control group (CG), without supplementation, and the treatment group (TG) got a high dose of oral cholecalciferol 2000 IU/day. Serum levels of 25(OH)D3 were measured using an enzyme-linked immunosorbent assay (ELISA).

Comparison between serum 25(OH)D3 levels and JIA subtypes, peripheral blood C- reactive protein (CRP), erythrocyte sedimentation rate (ESR), and Juvenile Arthritis Disease Activity Score (JADAS-27 Score) were analyzed using SPSS. There was a significant increase in serum 25(OH)D3 levels in treatment group (mean: 27.38 ± 6.39 ng/ml vs 42.26 ± 10.95 ng/ml; P=0.000). The JADAS-27 score significantly decrease in treatment group (14.60 ± 4.04 vs 6.24 ± 1.96; p= 0.000). Serum 25(OH)D3 showed a significant correlation with the JADAS-27 score. The levels of 25(OH)D3 are significantly decreased in children with JIA. Decreased 25(OH)D3 levels may be associated with the etiopathogenesis of JIA. Vitamin D levels have correlations with disease activity. Adjunctive treatment of cholecalciferol improves the disease activity in JIA patients.

Keywords: Disease activity, JIA, Pandemic Covid-19, Vitamin D

*Corresponding author:

E-mail: [email protected]

Introduction

Juvenile idiopathic arthritis (JIA) is a chronic inflammatory condition of joints characterized by arthritis for at least six weeks. Pandemic covid-19 makes children stay at home, and the intensity of sun exposure was decreased because of optimi- zation of indoor activity [1]. On the other hand, Indonesia is a tropical country that is rich in sun exposure, but the recent data showed many Indonesian children suffer from deficiency and insufficiency of vitamin D [2].

Previous studies indicated that vitamin D deficiency is associated with autoimmune diseases in pediatrics, such as systemic lupus erythema- tosus and JIA [3]. Recent in vitro studies have shown that vitamin D plays an important role in immune modulation by stimulating innate immu-

nity, enhancing its activity, and decreasing adap- tive immune activity [4]. This immunomodulatory action is explained by a decreased production of cytokines such as interleukin-2 and interferon- gamma, which is essential to the pro-inflammatory Th1 response, as well as an increased interleukin- 4 production, which is essential to the Th2 response [5]. Vitamin D also stimulates regulatory T cells while inhibiting Th17 and Th9 lymphocytes [6]. A previous study reported low levels of vitamin D in JIA patients. Moreover, studies suggest that 25-hydroxyvitamin D3 (25(OH)D3) is negatively associated with JIA disease activity before pandemic Covid-19 [1].However, there is no data on how the clinical profile and level of 25(OH)D3 during the pandemic in JIA Indonesian

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children.

Material and Methods Patients and Methods

This randomized-controlled trial was conducted at the Pediatric Department of Allergy Immunology Saiful Anwar Hospital, Indonesia, from June to September 2021. The diagnosis and classification of JIA were made based on the classification and diagnostic criteria for JIA by the International League of Associations for Rheuma- tology (ILAR). Fifty-one patients fulfill the inclusion criteria of JIA. Patients with JIA were randomized into two groups, the control group (CG) without supplementation and the treatment group (TG) got a high dose of oral cholecalciferol (Gracia Pharmindo Co., Ltd) 2000 IU per day for three months. Both groups received the standard treatment of ibuprofen, glucocorticoids, and methotrexate.

Blood Sampling

Venous blood samples were collected into vacutainer tubes for complete blood count exam- ination and serum analysis. The coagulated blood was centrifuged for 10 minutes at 3,000 rpm; the serum was aliquoted into sterile tubes and stored frozen at -20°C until analysis. Serum vitamin D levels (25-hydroxyvitamin D; 25(OH)D) were measured by enzyme-linked immunosorbent assay (ELISA) with a commercial 25-OH Vitamin D Human ELISA Kit (NovaTeinBio, Greater Bos- ton, USA). The presence of vitamin D antigen in the sample will be captured with an antigen-specific antibody. The detection antibody is then co- valently attached to the enzyme-linked secon-dary antibody. Enzyme substrate was then added to the wells producing a visible signal that is corre-lated with the amount of antigen and measured by a spectrophotometer. Vitamin D deficiency was de- fined as serum 25(OH)D<20 ng/mL, insufficiency as 20-30 ng/mL, and sufficiency as >30 ng/mL[6].

Measurement of disease activity

Disease activity score (JADAS) was calcu- lated as the linear sum of the scores of its four components: physician global assessment (VAS), the parent or global patient assessment (VAS), active joint count (swollen joint count and tender joint count), normalized ESR (range 0 to 10). Nor- malized ESR values were obtained according to

the following formula: [ESR (mm/hour) – 20] divided by 10. Before performing the calculation, ESR values < 20mm/hour were converted to 0 and ESR values > 120 mm/hour were converted to 120[7].

Ethics Statement

The study protocol was approved by the Ethics Commission of General Hospital Dr. Saiful Anwar Malang, No: 400/092/K3/302/2021. The informed consent was signed by the parents of all partici- pants.

Statistical Analysis

After the data is obtained, then data analysis is carried out using the SPSS version 25.0 program (IBM Corporation, New York City, USA). The difference was considered significant when p<0.05.

Results and Discussion

JIA is a common rheumatic disease in childhood. This study showed 51 JIA patients consisting of 31 girls and 20 boys oligoarticular (45%) as a subtype of JIA. It was similar to the cohort study of JIA [8]. Positive results of RF were detected in 15 patients. RF is related to a non- specific immune complex formation such as viral diseases [9]. C-reactive protein (CRP) levels, as well as leukocyte counts, were also signifi-cantly higher than the control group. During the pandemic, Covid-19 JIA patients had low levels of vitamin D. JIA patients suffered from deficiency (35.2%) and also insufficiency (35.2%) of vitamin D. Clinical trials previously have investigated the clinical benefits of vitamin D supplementation on rheumatic diseases [5]. The control group consisted of 26 children (15 girls and 11 boys) with a median age of 12.92 ± 2.56. The nutritional status was well-nourished in 9 patients in the control group, and statistically significant difference in nutritional status (p: 0.001). The median level of vitamin D serum was 18.94 ± 7.87 (CG) and 27.38 ± 6.39 (TG). Based on serum 25(OH)D3 level, it was found that 16 (41%) children in CG and 2 (3.9%) in TG suffered from a deficiency of vitamin D. Total JADAS-27 score did not significantly differ between 2 groups (p= 0.733).

The type of JIA 25 (51%) was oligoarthritis (Table 1).

Vitamin D has been known that is very benefi- cial for bone health. Evidence from recent studies

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suggests that vitamin D deficiency is closely associated with rheumatic conditions, including JIA in children. The fact that vitamin D inactivates Th1 and Th17, both of which are known to have roles in the pathophysiology of JIA, supports the notion that vitamin D is associated with JIA [10].

JIA pathomechanism is still not known for sure, but it is suspected that the immune process is closely involved in the pathogenesis. Both anti- gens and autoantigens are recognized by antigen- presenting cells (APCs), which then present antigenic peptides via class II Major Histocompa- tibility Complex (MHC) receptors to CD4+ T- helper cells that recognize antigenic peptides via the T cell antigen receptor (TCR). Activated T- helper cells secrete various cytokines and recruit other T cells and B cells that are stimulated to differentiate into antibody-producing plasma cells. On JIA, CD4+ T cells will actively accumulate in the joint space. Macrophages and fibro-

blasts produce IL-1 and TNF-α, which accumulate in the synovial membrane. These cytokines have broad effects on many cells and cause further activation and proliferation of T cells, increased activity of prostaglandins and matrix-destroying proteases, and bone resorption [11]. Vitamin D levels were analyzed based on pre (27.38 ± 6.39) and post-treatment (42.26 ± 10.95) in the treatment group (TG) and were significantly different (p = 0.000).

Both treatment groups also showed significant differences in JADAS-27 score ( pre 14.60 ± 4.04 VS post 6.24 ± 1.96, p= 0.000). Besides vitamin D levels and JADAS-27 score, there were also significant differences between ESR and CRP in pre and post-treatment supplementation of cholecalciferol in treatment groups (Table 2).

A study conducted by Pelajo et al. [12] in Boston, US, assessed the relationship between vitamin D levels and JIA. In his study, it was found Table 1. Baseline characteristics between groups

Parameters Control Group

(n=26)

Treatment Group (n=25)

P value Sex

Female 15/26 16/25 0.645

Male 11/26 9/25

Age (years) 12.92 ± 2.56 11.64 ± 0.91 0.052

Nutritional status

Well nourish 9/26 20/25 0.001*

Underweight 17/26 5/25

Laboratory results

Hemoglobin levels (g/dl) 10.79 ± 1.52 12.45 ± 0.69 0.064

White blood cell count (mm³) 9437.69 ± 2574.58 7865.20 ± 1171.32 0.011*

Thrombocyte count x10³(/mm³) 301.73 ± 107.54 272.04 ± 72.61 0.166

ESR (mm/hr) 33.58 ± 16.72 41.44 ± 17.51 0.687

CRP serum level (mg/L) 3.24 ± 2.55 0.62 ± 0.47 0.000*

Vitamin D serum level (ng/ml) 18.74 ± 7.89 28.28 ± 6.29 0.932 Classification of vitamin D

Deficiency (<20 ng/ml) 16/26 2/25

Insufficiency (20-30 ng/ml) 8/26 10/25

Sufficiency (>30 ng/ml) 2/26 13/25

Total JADAS-27 score 14.14 ± 4.24 14.60 ± 4.06 0.733

JIA Subtype

Oligoarthritis 13/26 12/25

RF negative polyarthritis 4/26 5/26

RF positive polyarthritis 8/26 7/25

Systemic arthritis 1/26 1/25

Treatment

NSAID 26/26 25/25

Corticosteroids 13/26 12/25

Metothrexate 12/26 11/25

*p < 0.05 was considered significant

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that 23% of patients with autoimmune conditions had vitamin D deficiency, while only 14% of patients without autoimmune conditions had vitamin D deficiency. After adjusting the measure- ments for ethnicity, season, and BMI, the odds ratio was 2.3 between patients with autoimmune disease and patients without autoimmune disease.

However, serum 25(OH)D levels in JIA patients were not significantly different from levels in patients with other autoimmune disorders such as SLE, vasculitis, dermatomyositis, and scleroder- ma. This study could not find a significant relationship between vitamin D levels and the activity of autoimmune diseases, including JIA. The researcher stated that this might be due to the lack of samples [12]. Another possibility is that there are many types of autoimmune diseases while serum vitamin D levels may actually be different in each disease so that when put together, the differences are not visible.The results of this study are in line with the cross-sectional study of Munekata et al. [13] in Brazil of 30 polyarticular JIA patients compared with 30 healthy individu- als. Researchers found no significant difference in 25(OH)D levels in the two groups. A total of 26.7% of JIA patients and 16.7% of the control group had 25(OH)D deficiency (<20 ng/ml) and 46.7% of JIA patients and 60% of the control group had insufficiency (20-32 ng/ml). This value is also not related to disease activity, medication, or bone mineral density. The researcher stated that

this result was probably due to the choice of the 25(OH)D measurement method and the 25(OH)D deficiency and insufficiency threshold values used [13]. The interpretation of vitamin D levels expressed as adequate levels is also controversial.

For several years, “normal” vitamin D levels were considered the levels necessary to maintain normal parathyroid hormone (PTH) values.

However, recent data show that the effects of vitamin D on the body are increasingly diverse, so the ideal vitamin D level may be much higher than the initial limit. The majority of experts define vitamin D deficiency as 25(OH)D levels less than 20 ng/mL (50 nmol/L) and insufficiency at levels 21-29 ng/mL (52-72 nmol/L) with an optimal value of more than 30 ng/mL (70 nmol/L).Vitamin D deficiency itself is still divided into severe deficiency (≤10 ng/mL) and deficiency (11-20 ng/mL) [14].

We compared the mean ESR and CRP in all treatment groups with the control group and found statistically significant differences (p = 0.000) (Figure 1 (a) and (b)). Our study showed there was a strong negative correlation between 25(OH)D3 levels with JADAS-27 score in JIA children (r = - 0.630; p = 0.001) in treatment groups. Other research reported that there was a negative correlation between vitamin D levels and JIA disease activity as measured using the JADAS-27.

Insufficiency of vitamin D levels (serum vitamin D: 15-20 ng/ml) was found in 19.1% of JIA Table 2. Comparison between pre and post Vitamin D treatment supplementation

Parameters Pre Treatment Post treatment P value

Control Group

ESR (mm/hr) 34.57 ± 16.71 28.00 ± 10.83 0.000*

Vitamin D serum level (ng/ml) 18.94 ± 7.87 27.86 ± 6.72 0.000*

Total JADAS-27 score 14.14 ± 4.24 11.07 ± 3.75 0.000*

Patients VAS 4.57 ± 1.23 3.57 ± 1.23 0.000*

Physician VAS 4.30 ± 1.05 3.46 ± 0.98 0.000*

Joint count 3.88 ± 2.32 3.07 ± 2.11 0.000*

Normalized ESR 1.37 ± 1.18 0.96 ± 0.85 0.000*

Treatment Group

ESR (mm/hr) 42.44 ± 17.51 28.00 ± 4.68 0.000*

Vitamin D serum level (ng/ml) 27.38 ± 6.39 42.26 ± 10.95 0.000*

Total JADAS-27 score 14.60 ± 4.04 6.24 ± 1.96 0.000*

Patients VAS 4.56 ± 1.26 2.16 ± 1.17 0.000*

Physician VAS 4.24 ± 1.01 1.60 ± 0.50 0.000*

Joint count 3.56 ± 1.85 1.68 ± 0.98 0.000*

Normalized ESR 2.24 ± 1.75 0.80 ± 0.47 0.000*

*p < 0.05 was considered significant

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patients, while cases of vitamin D deficiency (vitamin D levels <15 ng/ml) were found in 53.2%

of patients. In this study, there was a significant negative correlation between vitamin D levels and JIA disease activity, with JADAS-27 values being higher in patients with vitamin D levels <15 ng/ml compared to patients with vitamin D levels >15 ng/ml ( p = 0.003) [3]. However, a study in Turkey concluded that there was no significant difference in vitamin D levels of JIA patients during the active phase with the remission phase [10]. In addition, no correlation was found between vita-

min D levels and treatment regimens as well as parameters used to assess disease activity such as CRP, number of joints with arthritis, and Visual Analog Scale (VAS). Low levels of vitamin D in JIA patients may be due to a lack of sun exposure.

Loss of appetite in patients may also be a contri- buting factor that causes this vitamin D deficiency.

Similar results were obtained in another study of JIA patients in Morocco, where 75% of patients were found to be deficient in vitamin D [15]. From univariate analysis, it was found that 25(OH)D levels had a negative relationship with the Disease

(a) (b)

(c) (d)

Figure 1. (a) Mean ESR level between control group and treatment group, (b) Mean CRP level between control group and treatment group, (c) Total JADAS-27 score between control group and treatment group, (d) Mean Vitamin D level between control group and treatment group. Color description: Blue= Control Pre, Green= Treatment Pre, Yellow= Control Post, Violet= Treatment Post.

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Activity Score (DAS) for polyarticular JIA cases and oligoarticular. Another study by Stagi et al.

[16] was conducted on 152 JIA patients with a mean age of 16.2 ± 7.4 years. In this study, it was found that 25(OH)D levels were significantly reduced in JIA patients compared to the control group, even when these patients were divided into several subtypes (oligo-arthritis, polyarticular, systemic, and arthritis-associated enthesitis).

Patients with active or recurrent disease had lower 25(OH)D levels compared with patients with the inactive disease [16].

We also compared the JADAS-27 score and mean levels of 25(OH)D in all treatment groups with the control group and found statistically significant differences (p = 0.000) (Figure 1c) and

(d)). Indonesia is a tropical country that is rich in sun exposure. The latitude of an area and sun exposure also affect serum vitamin D levels.

Perhaps because of this, research on vitamin D or its effect on JIA conducted in different areas gave different results. A study conducted in the equatorial region of Fortazela, Brazil, found that 52% of JIA patients had optimal levels of 25(OH)D, 40% had adequate vitamin D levels, and 8% had vitamin D deficiency (<20 ng/mL).

Serum 25(OH)D levels did not differ significantly between JIA categories, disease activity, severity as measured by JADAS-27, Childhood Health Assessment Questionnaire (CHAQ), or joint

deformity. This study is said to be the first study of 25(OH)D levels in JIA patients living in the equatorial region, which shows the prevalence of deficiency in vitamin D ever reported. This low prevalence may be related to sun exposure compared to people living at higher latitudes. This strengthens the relevance of geographic variation to analyze 25(OH)D levels in patients [17]. There was a strong negative correlation between 25(OH)D3 levels with JADAS-27 score in JIA children (r = - 0.630; p=0.001) in treatment groups (Figure 2).

Recent research from Marginean et al.

involved 44 JIA patients diagnosed according to ILAR criteria and 13 patients in the control group [18]. With age and sex-adjusted between groups

and without any musculoskeletal complaints, it was found that vitamin D levels in JIA patients were shown to be significantly lower than those in the control group, especially in cases of systemic JIA and seropositive polyarticular arthritis [18]. A total of 66% of patients with arthritis are known to have vitamin D deficiency. Vitamin D levels are also known to have a significant correlation with the number of actively involved joints, the number of joints with radiologically visible lesions, and the duration of the disease. Vitamin D deficiency is thought to be related to the severity and duration of JIA disease. Researchers in this journal recommends routinely checking vitamin D levels Figure 2. Correlation between vitamin D level and JADAS-27 score in treatment group (r=-0.630, p=0.001)

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for JIA patients and giving vitamin D supplementation if needed.Management of JIA should be according to specific patient conditions, especially during pandemic Covid-19. Medication is needed to minimize inflammation of the joint and reduce the disease activity. Vitamin D can be considered as an adjunctive treatment for JIA patients during pandemic Covid-19. The limitations of the study were the lack of available information about nutrient intake that consists of vitamin D and the timing of sun exposure which may have confounding factors of 25(OH)D3 levels.

Conclusion

Our findings have shown a strong correlation between serum 25(OH)D3 and disease activity in JIA. The pediatrician should be aware risk of deficiency of vitamin D in a patient with JIA during pandemic Covid-19. Supplementation of vitamin D in children with JIA should be considered to prevent the active disease of JIA.

Acknowledgement

This research was funded by LPPM Universitas Brawijaya and supported by the Pediatric Department Saiful Anwar Hospital and

LAURA (Lupus, Autoimmune and

Rheumatology) research group, Faculty of Medicine, Universitas Brawijaya, Indonesia.

References

1. Wulandari D, Barlianto W, Sari TL (2020) Low Level of Vitamin D is Correlated with High C-Reactive Protein (CRP) and Disease Activity in Indonesian Juvenile Idio- pathic Arthritis (JIA) Patients. The Indonesian Biomedi- cal Journal 12 (2): 149–56. doi:

10.18585/inabj.v12i2.1143.

2. Soesanti F, Pulungan A, Tridjaja B, Batubara JR (2013) Vitamin D profile in healthy children aged 7-12 years old in Indonesia. International Journal of Pediatric Endocri- nology 2013 (Suppl 1): P167. doi: 10.1186/1687-9856- 2013-S1-P167.

3. Çomak E, Doğan ÇS, Uslu-Gökçeoğlu A et al. (2014) As- sociation between vitamin D deficiency and disease activity in juvenile idiopathic arthritis. The Turkish Journal of Pediatrics 56 (6): 626–631.

4. Alyasin S, Moghtaderi M, Rahimi M et al. (2014) Clinical and Serological Findings in Juvenile Patients with Idio- pathic Arthritis in Southwestern of Iran. International Journal of Pediatrics 2 (4.1): 331–338. doi:

10.22038/ijp.2014.3164.

5. Franco AS, Freitas TQ, Bernardo WM, Pereira RMR (2017) Vitamin D supplementation and disease activity in

patients with immune-mediated rheumatic diseases: A systematic review and meta-analysis. Medicine 96 (23):

e7024. doi: 10.1097/MD.0000000000007024.

6. Charoenngam N, Holick MF (2020) Immunologic Effects of Vitamin D on Human Health and Disease. Nutrients 12 (7): E2097. doi: 10.3390/nu12072097.

7. Nisar MK, Masood F, Cookson P et al. (2013) What do we know about juvenile idiopathic arthritis and vitamin D? A systematic literature review and meta-analysis of current evidence. Clinical Rheumatology 32 (6): 729–

734. doi: 10.1007/s10067-012-2159-1.

8. Yilmaz M, Kendirli SG, Altintas DU et al. (2008) Juve- nile idiopathic arthritis profile in Turkish children. Pedi- atrics International: Official Journal of the Japan Pediatric Society 50 (2): 154–158. doi: 10.1111/j.1442- 200X.2008.02543.x.

9. Kahn P (2012) Juvenile idiopathic arthritis: an update for the clinician. Bulletin of the NYU hospital for joint diseases 70 (3): 152–166.

10. Dağdeviren-Çakır A, Arvas A, Barut K et al. (2016) Se- rum vitamin d levels during activation and remission pe- riods of patients with juvenile idiopathic arthritis and fa- milial mediterranean fever. The Turkish Journal of Pedi- atrics 58 (2): 125. doi: 10.24953/turkjped.2016.02.001.

11. Zou J, Thornton C, Chambers ES et al. (2020) Exploring the Evidence for an Immunomodulatory Role of Vitamin D in Juvenile and Adult Rheumatic Disease. Frontiers in

Immunology 11 616483. doi:

10.3389/fimmu.2020.616483.

12. Pelajo CF, Lopez-Benitez JM, Miller LC (2011) 25-hydroxyvitamin D levels and vitamin D deficiency in children with rheumatologic disorders and controls. The Jour- nal of Rheumatology 38 (9): 2000–2004. doi:

10.3899/jrheum.110123.

13. Munekata RV, Terreri MTRA, Peracchi OAB et al.

(2013) Serum 25-hydroxyvitamin D and biochemical markers of bone metabolism in patients with juvenile idiopathic arthritis. Brazilian Journal of Medical and Biolog- ical Research 46 (1): 98–102. doi: 10.1590/1414- 431X20122477.

14. von Scheven E, Burnham JM (2011) Vitamin D supplementation in the pediatric rheumatology clinic. Current Rheumatology Reports 13 (2): 110–116. doi:

10.1007/s11926-010-0161-7.

15. Bouaddi I, Rostom S, El Badri D et al. (2014) Vitamin D concentrations and disease activity in Moroccan children with juvenile idiopathic arthritis. BMC musculoskeletal disorders 15 115. doi: 10.1186/1471-2474-15-115.

16. Stagi S, Bertini F, Cavalli L et al. (2014) Determinants of vitamin D levels in children, adolescents, and young adults with juvenile idiopathic arthritis. The Journal of Rheumatology 41 (9): 1884–1892. doi:

10.3899/jrheum.131421.

17. de Sousa Studart SA, Leite ACRM, Marinho ALLF et al.

(2015) Vitamin D levels in juvenile idiopathic arthritis from an equatorial region. Rheumatology International 35 (10): 1717–1723. doi: 10.1007/s00296-015-3287-0.

18. Mărginean O, Militaru AS, Belei O et al. (2017) vitamin d and its clinical significance in juvenile idiopathic arthritis. Jokull Journal 67 (6): 19-30

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