全科醫生小詞典
——公共衛生監測

公共衛生監測是指連續地、系統地收集、分析和解釋特定疾病或衛生事件的資料，據此制定、實施和評價公共衛生行動。醫學領域的監測屬公共衛生工作范疇，其根本目的是降低死亡，減少疾病，改善群體水平的健康狀況。

公共衛生監測一般而言包含以下幾個環節：一是收集，指系統性、持續性收集某方面的資料。二是分析，對收集的資料進行匯總和分析，得到有價值的結果信息。三是解釋，對分析得到的結果進行解釋，即分析結果中包含了什么樣的公共衛生信息，以及這樣的結果信息如何用于公共衛生行動，如制定新的政策或改變原有的政策或行動。四是發布，把有用的結果信息向相關人員報告，達到信息傳達或分享的目的。五是用于公共衛生行動。主要用于評價公共衛生狀況，確定公共衛生問題或有限領域，評價公共衛生項目，促進醫學研究。

按照定義，如果下級單位常規上報監測數據和資料，而上級單位被動接受，稱為被動監測，根據特殊需要上級部門專門調查或要求下級單位嚴格按照規定收集資料，稱為主動監測。此外，為了更加清楚地了解某些疾病在不同地區、不同人群的分布以及相應的影響因素等，根據被監測疾病的流行特點，選擇若干有代表性的地區和人群，按照統一的監測方案連續地開展監測稱之為哨點監測。

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 Sj?gren′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?"