Risk factors of prolonged diarrhea in children under 2 years old.

BACKGROUND: Prolonged diarrhea, defined as diarrhea lasting longer than 7 days, is known to negatively impact children's growth and development. However, studies of the risk factors of prolonged diarrhea remain limited. PURPOSE: This study aimed to analyze the risk factors for prolonged diarrhea in children under 2 years of age with acute diarrhea. METHODS: This 1-year nested case-control study was conducted at Fatmawati General Hospital in 2021-2022. Participants were selected using a consecutive sampling method from among children under 2 years of age with acute diarrhea within the previous 2-4 days. Children with diarrhea that lasted 7 days were considered positive for prolonged diarrhea, whereas those with acute diarrhea were considered negative. Children with comorbidities such as malnutrition were excluded. Clinical information including age, breastfeeding history, antibiotic exposure history, and nutritional status was recorded. Complete blood count, blood zinc levels, Rotavirus, adenovirus, and norovirus serology, alpha-1 antitrypsin (AAT) levels, and stool analysis were acquired as laboratory data. RESULTS: There were 62 subjects in the study and control groups. Overall, the median age was 12 months (6-24 months); most patients were boys. A history of antibiotic use (odds ratio [OR], 15.860; 95% confidence interval [CI], 5.286-47.591; P<0.001), zinc deficiency (OR, 4.758; 95% CI, 1.711-13.229; P=0.003), and elevated fecal AAT levels (OR, 2.677; 95% CI, 1.046-6.850; P=0.040) were the main risk factors for prolonged diarrhea in children under 2 years of age with acute diarrhea. CONCLUSION: A history of antibiotic use, zinc deficiency, and elevated fecal AAT levels were the main risk factors for prolonged diarrhea in children under 2 years of age with acute diarrhea. Thorough testing and appropriate antibiotic use are required to prevent prolonged diarrhea in children under 2 years of age.

Hematological Parameters in Individuals with Beta Thalassemia Trait in South Sumatra, Indonesia.

Background: ß-Thalassemia has a very wide clinical variation, depending on the severity of the patient's condition. Individuals with ß-thalassemia traits are usually asymptomatic; however, laboratory examination will show mild anemia with microcytic hypochromic erythrocytes morphology with wide variation depending on the genotype. This study was conducted to determine the reference value of hematological parameters and hemoglobin (Hb) analysis based on the phenotype of ß-thalassemia (ß 0 and ß +) and determine the differences of hematological characteristics between the two phenotypes. Methods: This cross-sectional study was conducted by evaluating the hematological parameters and Hb analysis of the ß-thalassemia trait in the family of thalassemia patient population. The subjects were divided into ß 0 and ß +. The subject with normal Hb analysis with or without iron deficiency was excluded. Results: A total of 203 subjects with thalassemia traits were included from the families of thalassemia patients, consisting of 101 subjects with ß 0-thalassemia, 82 subjects with ß +-thalassemia, and the mutation had not been found in 20 subjects. There was a relationship in the mean/median of hematological parameters, HbA2 and HbF, between ß 0-thalassemia and ß +-thalassemia (P < 0.05). ROC for each hematological parameter, HbA2 and HbF, showed that the highest diagnostic value based on the area under the curve was mean corpuscular hemoglobin (MCH) (0.900) and mean corpuscular volume (MCV) (0.898). The cutoff point of MCH for ß 0-thalassemia trait was ≤20.5 pg (sensitivity 85%, specificity 90%) and MCV was ≤66.8 fL (sensitivity 87%, specificity 87%). Conclusion: MCH values can be used as a screening tool for predicting ß 0-thalassemia in the relatives of thalassemia patients in the South Sumatra population.

The role of clopidogrel resistance-related genetic and epigenetic factors in major adverse cardiovascular events among patients with acute coronary syndrome after percutaneous coronary intervention.

Despite patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI) and receiving clopidogrel therapy, some patients still experience major adverse cardiovascular events (MACEs). Clopidogrel resistance, which may be regulated by genetic and epigenetic factors, may play a role in MACEs. This study aimed to determine the association between genetic (CYP2C19 and P2Y12 polymorphisms) and epigenetic (DNA methylation of CYP2C19 and P2Y12 and miRNA-26a expression) factors and their effects on MACEs among post-PCI patients. Post-PCI patients who received a standard dosage of clopidogrel at Harapan Kita Hospital between September 2018 and June 2020 were included in this study. MACEs were observed in patients within 1 year after PCI. Platelet aggregation was assessed using light transmission aggregometry (LTA). DNA methylation of CYP2C19 and P2Y12 was assessed using the bisulfite conversion method. CYP2C19 and P2Y12 polymorphisms and miRNA-26a expression were evaluated using quantitative real-time polymerase chain reaction (qRT-PCR). Among a total of 201 subjects, 49.8% were clopidogrel-resistant, and 14.9% experienced MACEs within 1 year after PCI (death was 7.5%). Hypomethylation of CYP2C19 (p = 0.037) and miRNA-26a upregulation (p = 0.020) were associated with clopidogrel resistance. CYP2C19*2/*3 polymorphisms (p = 0.047) were associated with MACEs in 1 year. This study demonstrated that hypomethylation of CYP2C19 and miRNA-26a upregulation increased the risk of clopidogrel resistance in post-PCI patients, but there was no correlation between clopidogrel resistance and MACEs. However, CYP2C19*2/*3 polymorphisms were the factors that predicted MACEs within 1 year.

Development of Food Multi-Mix Using a Linear Programming Approach to Fill the Nutrient Gap of Amino Acids and Micronutrients for Stunted Non-Wasted Children.

Food-based approaches using locally available food escalates the feasibility and the sustainability of nutrition intervention. A complementary feeding recommendation (CFR) integrated with the food multi-mix (FMM) formulation was targeted to fulfill micronutrient and amino acid requirements for stunted non-wasted (SNW) children aged 12-23 months living in agricultural areas. A seven-day estimated food record (EFR) of 87 children was used to design the CFR and 4 identified underutilized foods were integrated as the FMM. A linear programming approach using Optifood was applied to optimize the CFR and FMM. CFR alone successfully fulfills the vitamin C, riboflavin, iron, and zinc, but it cannot fulfill calcium, thiamin, niacin, vitamin B6, folate, vitamin B12, and histidine. With the incorporation of the selected underutilized cowpea, buncis batik, wader fish, and cows' milk in the FMM development, the nutrients that are challenging in CFR development, can be fulfilled. Therefore, these findings present evidence that food multi-mix developed based on locally available nutrient-dense food sources can help to meet the nutrient gaps, which often remained even after a complementary feeding diet is optimized. Efficacy study using the developed CFR and FMM is recommended to assess effect in improving intake of micronutrients and amino acids and improving the linear growth of stunted, non-wasted children.

Irritable bowel syndrome in Indonesian adolescents

Abstract Objective: Irritable bowel syndrome is a frequent functional gastrointestinal disorder. The aims of this study were to investigate its epidemiology, focusing on the role of intestinal mucosal integrity and to evaluate the impact on the quality of life. Methods: A community-based survey applying a comparative cross sectional approach was conducted in six high schools in Palembang. Subjects were recruited using multistage random sampling divided in two groups. Rome III criteria were used to establish a diagnosis of IBS in combination with a questionnaire to determine risk factors. Determination of fecal alpha-1-antitrypsin and calprotectin levels was performed to determine impaired intestinal mucosal integrity. A questionnaire was used to evaluate how quality of life was affected by irritable bowel syndrome. Results: The survey was performed in 454 14−18 years old adolescents, of whom 30.2% fulfilled the Rome III criteria for IBS, with the following subtypes: 36.5% diarrhea, 18.9% constipation, 21.9% mixed, and 22.6% unclassified. Major risk factors were female gender, bullying, age 14-16 years, history of constipation and diarrhea, eating nuts, and drinking coffee, tea, and soft drinks. There was a significant association with intestinal inflammation (p = 0.013). A significantly impaired quality of life was found (p = 0.001). Conclusions: The prevalence of irritable bowel syndrome in adolescents was high, with bullying, female gender, age 14-16 years, constipation and diarrhea, and dietary consumption of soft drinks, coffee, and tea as risk factors. A significant association with intestinal inflammation was found.

Irritable bowel syndrome in Indonesian adolescents.

OBJECTIVE: Irritable bowel syndrome is a frequent functional gastrointestinal disorder. The aims of this study were to investigate its epidemiology, focusing on the role of intestinal mucosal integrity and to evaluate the impact on the quality of life. METHODS: A community-based survey applying a comparative cross sectional approach was conducted in six high schools in Palembang. Subjects were recruited using multistage random sampling divided in two groups. Rome III criteria were used to establish a diagnosis of IBS in combination with a questionnaire to determine risk factors. Determination of fecal alpha-1-antitrypsin and calprotectin levels was performed to determine impaired intestinal mucosal integrity. A questionnaire was used to evaluate how quality of life was affected by irritable bowel syndrome. RESULTS: The survey was performed in 454 14-18years old adolescents, of whom 30.2% fulfilled the Rome III criteria for IBS, with the following subtypes: 36.5% diarrhea, 18.9% constipation, 21.9% mixed, and 22.6% unclassified. Major risk factors were female gender, bullying, age 14-16 years, history of constipation and diarrhea, eating nuts, and drinking coffee, tea, and soft drinks. There was a significant association with intestinal inflammation (p=0.013). A significantly impaired quality of life was found (p=0.001). CONCLUSIONS: The prevalence of irritable bowel syndrome in adolescents was high, with bullying, female gender, age 14-16 years, constipation and diarrhea, and dietary consumption of soft drinks, coffee, and tea as risk factors. A significant association with intestinal inflammation was found.

Effect of Supplementation of Zinc, Glutamine, Fiber, and Prebiotics in Presumed Healthy Indonesian Children Aged 1-3 Years.

PURPOSE: Impaired intestinal mucosal integrity may affect the gastrointestinal function, especially in relation to nutrition, absorption, and barrier function. The purpose of this study was to measure the prevalence of impaired intestinal mucosal integrity in presumed healthy children aged 1-3 years and assess the effects of zinc, glutamine, fiber, and prebiotic supplementation in them. METHODS: A cross-sectional study was conducted in 200 children aged 1-3 years in Pasar Minggu, South Jakarta, Indonesia. A randomized double-blind parallel group method clinical trial was then performed to assess the effects of zinc, glutamine, fiber, and prebiotic supplementation. RESULTS: Elevated calprotectin was found in 91/200 subjects (45.5%) at the onset of the study. After 10 months, 144 subjects completed the study: 72 subjects received the trial formula, whereas the other 72 received the standard formula. A transitory decrease in fecal calprotectin (FC) was observed after 6 months in the subgroup with normal FC levels, who were fed the test formula (p=0.012). CONCLUSION: The prevalence of impaired intestinal mucosal integrity in this group of Indonesian children aged 1-3 years was high. Supplementation with zinc, glutamine, fiber, and prebiotics during 6 months reduced FC only in those who had low levels at baseline but not in those with impaired integrity.

Cardiac Performance by Echocardiography, Cardiovascular Biomarker, Kidney Function, and Venous Oxygen Saturation as Mortality Predictors of Septic Shock.

BACKGROUND: cardiac function in patients with septic shock at the cellular level can be assessed by measuring troponin I and NT Pro BNP levels. Venous oxygen saturation is measured to evaluate oxygen delivery and uptake by organ tissue. Our study may provide greater knowledge and understanding on pathophysiology of cardiovascular disorder in patients with septic shock. This study aimed to evaluate the roles of echocardiography, cardiovascular biomarkers, venous oxygen saturation and renal function as predictors of mortality rate in patients with septic shock. METHODS: this is a prospective cohort study in patients with infections, hypotension (MAP < 65 mmHg) and serum lactate level of > 2 mmol/L. On the first and fifth days, septic patients underwent echocardiography and blood tests. Statistical analysis used in our study included t-test or Mann-Whitney test for numeric data and chi-square test for nominal data of two-variable groups; while for multivariate analysis, we used Cox Regression model. RESULTS: on 10 days of observation, we found 64 (58%) patients died and 47 (42%) patients survived. The mean age of patients was 48 (SD 18) years. Patients with abnormal left ventricular ejection fraction (LVEF) had 1.6 times greater risk of mortality than those with normal LVEF (RR 1.6; p = 0.034). Patients with abnormal troponin I level showed higher risk of mortality as many as 1.6 times (RR: 1.6; p = 0.004). Patients with impaired renal function had 1.5 times risk of mortality (RR 1.5; p = 0.024). Patients with abnormal troponin I level and/or impaired renal function showed increased mortality risk; however, those with normal troponin I level and impaired renal function also showed increased mortality risk. Multivariate analysis revealed that left ventricular ejection fraction and troponin I level may serve as predictors of mortality in patients with septic shock. (HR 1.99; 95% CI: 1.099  ̶  3.956 ; p = 0.047 and HR: 1.83 ; 95%CI: 1.049  ̶ 3,215 ; p = 0.043). CONCLUSION: left ventricular ejection fraction and biomarkers such as troponin I level are predictors of mortality in septic shock patients.

Urinary iron excretion for evaluating iron chelation efficacy in children with thalassemia major.

BACKGROUND: In patients with thalassemia major, examination routinely used for the evaluation of iron load in Indonesia is serum ferritin, but it is strongly influenced by other factors such as infections, inflammation and vitamin C levels. Evaluation of urinary iron excretion is an important and easy method to indicate iron chelation efficacy. OBJECTIVE: To determine the efficacy of iron chelation therapy by urinary iron examination and to evaluate its correlation with the time of transfusion, serum ferritin level, transferrin saturation and T2* MRI. METHODS: Prospective cohort study was conducted in children with thalassemia major aged 7-<18 years old who received DFP therapy. Twenty-four-hour urine collections were examined through inductively coupled plasma - mass spectrometry (ICP-MS). Patient's serum ferritin, transferrin saturation, peripheral blood, differential count and T2* MRI was documented during the study. Data analysis is based on urine iron level, body iron balance and the correlation between urine iron level, serum ferritin, transferrin saturation and T2* MRI and dosage of DFP. RESULTS: Thirty (55%) subjects showed a higher urine iron level on the day prior to transfusion (mean: 12,828 SD ±12,801 µg/24 h) in comparison to post transfusion (mean: 10,985 SD ±10,023 µg/24 h). All subjects had positive iron balance (mean 524 SD ±230 mg). There were positive correlation between urine iron level and transferrin saturation (r = 0.559, p = 0.01) and serum ferritin (r = 0.291, p = 0.03), no correlation found with T2* MRI results. CONCLUSIONS: There is a relationship to urinary iron excretion in response to chelation therapy and the degree of iron load.

Presentation, etiology, and outcome of brain infections in an Indonesian hospital: A cohort study.

BACKGROUND: Little detailed knowledge is available regarding the etiology and outcome of CNS infection, particularly in HIV-infected individuals, in low-resource settings. METHODS: From January 2015 to April 2016, we prospectively included all adults with suspected CNS infection in a referral hospital in Jakarta, Indonesia. Systematic screening included HIV testing, CSF examination, and neuroimaging. RESULTS: A total of 274 patients with suspected CNS infection (median age 26 years) presented after a median of 14 days with headache (77%), fever (78%), seizures (27%), or loss of consciousness (71%). HIV coinfection was common (54%), mostly newly diagnosed (30%) and advanced (median CD4 cell count 30/µL). Diagnosis was established in 167 participants (65%), including definite tuberculous meningitis (TBM) (n = 44), probable TBM (n = 48), cerebral toxoplasmosis (n = 48), cryptococcal meningitis (n = 14), herpes simplex virus/varicella-zoster virus/cytomegalovirus encephalitis (n = 10), cerebral lymphoma (n = 1), neurosyphilis (n = 1), and mucormycosis (n = 1). In-hospital mortality was 32%; 6-month mortality was 57%. The remaining survivors had either moderate or severe disability (36%) according to Glasgow Outcome Scale. CONCLUSION: In this setting, patients with CNS infections present late with severe disease and often associated with advanced HIV infection. Tuberculosis, toxoplasmosis, and cryptococcosis are common. High mortality and long-term morbidity underline the need for service improvements and further study.

Iron Absorption in Iron-Deficient Women, Who Received 65 mg Fe with an Indonesian Breakfast, Is Much Better from NaFe(III)EDTA than from Fe(II)SO4, with an Acceptable Increase of Plasma NTBI. A Randomized Clinical Trial.

Plasma non-transferrin-bound iron (NTBI) is potentially harmful due to the generation of free radicals that cause tissue damage in vascular and other diseases. Studies in iron-replete and iron-deficient subjects, receiving a single oral test dose of Fe(II)SO4 or NaFe(III)EDTA with water, revealed that FeSO4 was well absorbed when compared with NaFeEDTA, while only the Fe(II) compound showed a remarkable increase of NTBI. As NaFeEDTA is successfully used for food fortification, a double-blind randomized cross-over trial was conducted in 11 healthy women with uncomplicated iron deficiency. All subjects received a placebo, 6.5 mg FeSO4, 65 mg FeSO4, 6.5 mg NaFeEDTA, and 65 mg NaFeEDTA with a traditional Indonesian breakfast in one-week intervals. Blood tests were carried out every 60 min for five hours. NTBI detection was performed using the fluorescein-labeled apotransferrin method. Plasma iron values were highly increased after 65 mg NaFeEDTA, twice as high as after FeSO4. A similar pattern was seen for NTBI. After 6.5 mg of NaFeEDTA and FeSO4, NTBI was hardly detectable. NaFeEDTA was highly effective for the treatment of iron deficiency if given with a meal, inhibiting the formation of nonabsorbable Fe-complexes, while NTBI did not exceed the range of normal values for iron-replete subjects.

Pancreatic enzyme replacement therapy (PERT) in children with persistent diarrhea: avoidance of elemental diet need, accessibility and costs.

BACKGROUND AND OBJECTIVES: Persistent diarrhea has been proven to cause pancreatic exocrine insufficiency, due to decreased stimulation to the pancreas caused by prolonged mucosal injury. Pancreatic enzyme replacement therapy (PERT) given in conjunction to regular treatment is thought to be beneficial in replacing this pancreatic enzyme deficiency, avoiding the need of elemental diet. This study aims to evaluate the benefit of PERT in chil-dren with persistent diarrhea. METHODS AND STUDY DESIGN: This is a randomized, two double-blind parallel group, placebo-controlled clinical trial to evaluate the effects of pancreatic enzyme supplementation in persistent diar-rhea. Children age 6-60 months were recruited from pediatric inpatient and outpatient units of five hospitals in Jakarta. Subjects was randomly assigned to either pancreatic enzyme 8371 USP unit of lipase or placebo, 3 times daily for 1 month, as an adjunctive therapy to standard treatment. Subjects were then reevaluated at 2 weeks and 4 weeks interval after administration of enzyme or placebo. Variables observed were length of diarrhea after the start of intervention, change in serum prealbumin, and change in FE-1 between week 0 and week 4. RESULTS: Pan-creatic enzyme supplementation shortens the length of diarrhea by 7 days in the intervention group compared to placebo (p=0.019). Serum prealbumin and FE-1 shows trend that favors the intervention group, although not sta-tistically significant (p>0.05). CONCLUSION: PERT is clinically effective in reducing the length of diarrhea, thus minimizing the need, accessibility and costs of an elemental diet.

Pancreatic exocrine insufficiency in malnourished children and those with persistent diarrhoeae.

BACKGROUND AND OBJECTIVES: Persistent diarrhoea, a serious health problem, is closely related to malnutrition. Children with severe malnutrition have a 9-fold risk of death, and children with severe stunting have a 4-fold risk of death. Prolonged mucosal injury from diarrhoea causes reduced secretin and cholecystokinin secretion, which decreases stimulation to the pancreas, and is indicated by faecal elastase-1 levels. This further aggravates persistent diarrhoea and malnutrition because of the low levels of digestive enzyme production. This study evaluated the exocrine function of the pancreas in children with persistent diarrhoea and malnutrition. METHODS AND STUDY DESIGN: This study used a cross-sectional design to compare exocrine pancreatic function among children with persistent diarrhoea, children with malnutrition, and apparently healthy children as reference Children aged 6-60 months were selected from the inpatient and outpatient units of various general hospitals in Jakarta. Faecal elastase- 1 levels were used to determine exocrine pancreatic function. RESULTS: The median values of faecal elastase- 1 in children with persistent diarrhoea, children with malnutrition, and reference children were 743 (1-1503) mcg/g, 861 (17-2909) mcg/g, and 1210 (26-3000) mcg/g, respectively. A significant difference was observed in the faecal elastase-1 levels between reference children and those with persistent diarrhoea (p<0.001). However, no differences in the faecal elastase-1 levels were noted between malnourished and reference children (p>0.05). Children with both persistent diarrhoea and malnutrition showed mean FE-1 392.3±206.9 and median 419 (125- 593). CONCLUSIONS: Exocrine pancreatic insufficiency is found in children with persistent diarrhoea. Children with combined persistent diarrhoea and malnutrition have the lowest FE-1, to which persistent diarrhea has the most significant contribution.

The role of a novel digital microcapillary instrument in detecting blood and plasma hyperviscosity.

AIM: to test the precision and accuracy of a Digital Microcapillary instrument in measuring blood and plasma viscosity. METHODS: about 40 blood samples were drawn for precision test. The samples were obtained from patients admitted for Medical Check-Up at CiptoMangunkusumo Hospital (RSCM) in December 2011.Accuracy test was evaluated using cross-sectional design and involving 135 patients with acute ischemic stroke. The patients underwent either inpatients or outpatients care at Department of Clinical Pathology, Department of Neurology,and Emergency Unit of RSCM, Fatmawati Hospital Jakarta, Prikasih Hospital Jakarta, and Bhakti Yuda Hospital Depok. The precision test was evaluated by calculating the coefficient of variation (CV), interrater variability of Cronbach Alpha, and reliability coefficient of Bland Altman. The accuracy of the test was evaluated with a diagnostic test. The gold standard used for these tests was Brookfield LV-DV III viscometer. RESULTS: the results of precision test were: CV = 0.04; interrater variability of blood and plasma viscosity = 0.94 and 0.82, respectively; the Bland Altman mean difference = -0.19. The results of accuracy test were: sensitivity of blood and plasma viscosity measurement were 88.9% and 100%, respectively; specificity of blood and plasma viscosity measurement were 88.9% and 84%, respectively. CONCLUSION: the digital microcapillary has high sensitivity and specificity; therefore the instrument can be considered to be used as screening test tool to measure blood and plasma viscosity.

Some hematological problems in Indonesia.

Indonesia consist of many island inhabited by many ethnic groups with different social economic condition. As in other parts of the world, anemia is still one of the major health problem in Indonesia. The reported anemia prevalence differs in each area and age groups, ranging from 5.4% in well nourished preschool children to 56.3% in primary school children; and 19% to 62.5% in pregnant women. The causes of anemia mostly reported were nutritional like iron deficiency, abnormal hemoglobin besides other conditions. In Cipto Mangunkusumo Hospital as the national referral hospital in Indonesia, in the adults groups, the cause of anemia reported were 14% with iron deficiency, 54% aplastic, 16% hemolytic and 16% other causes. Whereas in the child health department the cause were 29% nutritional deficiency, 31% thalassemia, 10% aplastic, 4% hemolytic and 26% other causes. Thalassemia is quite often reported in Indonesia. In 1955 Lie-Injo first reported the HbE as the most frequently found abnormality among many ethnic groups in Indonesia, ranging from 2.5% to 13.2%. In later studies the prevalence reported varies very much. It was reported as 9.5% in newborns, 22% in pregnant women, and 15.95% to 60% in athletes. The carrier frequency in some areas was between 6-10%, while the pattern of mutation varied widely within each region. Hemophilia cases in Indonesia is still not diagnosed adequately, only 530 cases were reported. The problems were lack of diagnostic laboratories and awareness. As many as 56.9% of the hemophilia patients who received cryoprecipitate were reported positive with HCV antibody. Hematological malignancy is now also became an increasing problem in Indonesia, in child health department the prevalence of leukemia was 57%, and lymphoma 13% among other malignancies. In National Cancer hospital, the prevalence leukemia as diagnosed using morphology and flowcytometry, were 51.4% AML, 19.7% B-ALL, 14.6% T-ALL, 4.5% preB-ALL, with 9.8% cases with co expression, and 30% other malignancies. Due to geographical situation, economic condition and lack of diagnostic laboratory facility many abnormalities were unable to be diagnosed properly.

External quality assessment scheme and laboratory accreditation in Indonesia.

The National Program on External Quality Assessment Scheme (NEQAS) in Indonesia was first started in 1979, organized by the Indonesian Ministry of Health collaborating with professional bodies. The first trial was for clinical chemistry test with 2 cycles per year, followed by the hematology NEQAS in 1986 in collaboration with WHO-Royal Post Graduate Medical School London. After that, the schemes for serology, microbiology and parasitology were also organized. Around 500-600 laboratories throughout Indonesia participated each year in these quality control schemes, 2-4 cycles per year. Samples would be sent to participants and results will be given back to each laboratory. Poor performers should participate in the workshop or training course conducted by the Central Health Laboratory to improve their results. Participation in this NEQAS is mandatory for obtaining the laboratory license, and the Ministry of Health uses these schemes as one of the means for monitoring and coordinating the performance of laboratories throughout Indonesia. There are also some other EQAS (External Quality Assessment Scheme) programs conducted by professional bodies, such as for hemostasis, clinical chemistry and serology. During the course of conducting these schemes, it could be observed that manual methods were gradually changed to the automatic methods, especially for the clinical chemistry and hematology laboratories, which counts also for improvements of their results. Since the last 6 years, the Ministry of Health also began to conduct the Accreditation System evaluation for hospitals, including the laboratory departments. There are 7 standards that were evaluated, such as the aspect of the organization, administration and management, staffing, facilities and equipment, standard operating procedures, research and developments and quality control. This accreditation program is still in progress for all public and private hospital laboratories.

Evaluation of the stability of Cell Dyn 16 Tri Level as a control material for laboratory external quality assessment scheme on hematology.

The implementation of a laboratory test should always implement a laboratory quality control program, i.e internal quality control and external quality assessment. In an external quality assessment scheme, a control material that is stable over delivery until tested by the participating laboratory. In this study, we evaluated the stability of Cell Dyn 16 Tri Level (TL) control material at room temperature (26-32 degrees C), stored in a transport vessel containing ice pack, and the precision and accuracy of the instrument Cell Dyn 1400. The control used was Cell Dyn 16 TL with low value (L), normal value (N) and high value (H). This study was done in the Clinical Pathology Department of FKUI-RSCM during February 2001 until May 2001. Control material was stored room in a transport vessel containing ice pack for 15 days, then analysed macroscopically, microscopically and evaluated for its stability. Test for precision and accuracy was done within run and for precision between day on Cell Dyn 1400. The result of this study showed a macroscopic change beginning on day 14 (L) day 12 (N) and day 15 (H). Microscopic change was observed on day 13 (L and N) and day 15 (H), Erythrocyte and hemoglobin level was stable until day 15. Changes in leukocyte was seen on day 14 (L), day 12 (N) and day 15 (H). Platelet showed instability on day 9 (L), day 10 (N and H). Mean erythrocyte volume was out of range on day 15 (L), but the N and H control was still stable. The precision and accuracy of Cell Dyn 1400 was in WHO recommended range. We concluded that the precision and accuracy of Cell Dyn 1400 is good. Cell Dyn 16 TL control material was stable until day 9, and its can be recommended to be used as a control material for external quality assessment scheme.