全科医生小词典——公共卫生监测

公共卫生监测是指连续地、系统地收集、分析和解释特定疾病或卫生事件的资料，据此制定、实施和评价公共卫生行动。医学领域的监测属公共卫生工作范畴，其根本目的是降低死亡，减少疾病，改善群体水平的健康状况。

公共卫生监测一般而言包含以下几个环节：一是收集，指系统性、持续性收集某方面的资料。二是分析，对收集的资料进行汇总和分析，得到有价值的结果信息。三是解释，对分析得到的结果进行解释，即分析结果中包含了什么样的公共卫生信息，以及这样的结果信息如何用于公共卫生行动，如制定新的政策或改变原有的政策或行动。四是发布，把有用的结果信息向相关人员报告，达到信息传达或分享的目的。五是用于公共卫生行动。主要用于评价公共卫生状况，确定公共卫生问题或有限领域，评价公共卫生项目，促进医学研究。

按照定义，如果下级单位常规上报监测数据和资料，而上级单位被动接受，称为被动监测，根据特殊需要上级部门专门调查或要求下级单位严格按照规定收集资料，称为主动监测。此外，为了更加清楚地了解某些疾病在不同地区、不同人群的分布以及相应的影响因素等，根据被监测疾病的流行特点，选择若干有代表性的地区和人群，按照统一的监测方案连续地开展监测称之为哨点监测。

If I had a dollar for every time one of my elderly patients told me he or she felt tired,I′d be in a higher tax bracket.My 76-year-old patient Ellen′s chief complaint on her annual physical was fatigue,so I included a thyroid-stimulating hormone test along with her yearly complete blood count and chemistry panel.Everything was normal.

A week later Ellen called to say that she was feeling worse and now had a daily low-grade fever,anorexia,weakness and joint pains.Exhausting my repertoire of tests for these types of complaints,I had her come in for a rheumatoid factor,antinuclear antibodies (ANA) test,erythrocyte sedimentation rate,a Lyme titer,and blood and urine cultures.

Much to my surprise,her sedimentation rate was 90 mm/hr,and her ANA was positive."Ellen," I told her,"you have some kind of connective tissue disorder.It′s a little beyond my scope of expertise,so I′m going to call a rheumatologist for a consult." I started her on some low-dose prednisone,set her up for an abdominal computed tomography (CT) scan to rule out an occult malignancy,and said I′d get back to her.

Jack,the rheumatologist,gave me a curbside over the phone,recommending several tests with exotic names for diseases such as Sjögren′s syndrome and scleroderma.He also recommended an anti-DNA Ab and serum C3 and C4 complement to firm up the diagnosis of lupus,which he said was uncommon in the elderly.In the meantime,Ellen had experienced a syncopal episode while awaiting her CT scan,and a work-up in the emergency department disclosed a platelet count of 35 000/mm3."She′s improved on IV fluids," Tom,the ED doc,told me."Do you still want the CT?"

"Not now," I said,realizing that Ellen probably had a circulating anti-platelet antibody and the diagnosis of lupus was becoming much more likely."Give her 60 milligrams of prednisone p.o.and send her home."

Jack advised continuing the high-dose prednisone until her platelet count rose and discounted the risk of a bleed."If they′re not already bleeding,we don′t usually worry until their platelets hit 10 000 to 20 000," he said.He also recommended that I give a divided dose of the prednisone three to four times a day for better coverage.

Over the next several weeks,Ellen got better.First,her joint pains stopped,then her fevers abated,and finally she began to perk up.Her platelet count rose to 65 000/mm3after two weeks and was up in the normal range the next week,while her sedimentation rate dropped to 5 mm/hr.At her last visit she was upbeat,reporting an improved appetite and a weight gain of seven pounds.As an afterthought she said,"But I have these terrible sores in my mouth,Dr.Brown."

"Let′s see," I said,looking at a bad case of thrush."I think we can start tapering you off prednisone now,Ellen.What good′s an appetite if you can′t eat?"