全科醫(yī)生小詞典
——公共衛(wèi)生監(jiān)測(cè)

公共衛(wèi)生監(jiān)測(cè)是指連續(xù)地、系統(tǒng)地收集、分析和解釋特定疾病或衛(wèi)生事件的資料，據(jù)此制定、實(shí)施和評(píng)價(jià)公共衛(wèi)生行動(dòng)。醫(yī)學(xué)領(lǐng)域的監(jiān)測(cè)屬公共衛(wèi)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(wèi)生監(jiān)測(cè)一般而言包含以下幾個(gè)環(huán)節(jié)：一是收集，指系統(tǒng)性、持續(xù)性收集某方面的資料。二是分析，對(duì)收集的資料進(jìn)行匯總和分析，得到有價(jià)值的結(jié)果信息。三是解釋，對(duì)分析得到的結(jié)果進(jìn)行解釋，即分析結(jié)果中包含了什么樣的公共衛(wèi)生信息，以及這樣的結(jié)果信息如何用于公共衛(wèi)生行動(dòng)，如制定新的政策或改變?cè)械恼呋蛐袆?dòng)。四是發(fā)布，把有用的結(jié)果信息向相關(guān)人員報(bào)告，達(dá)到信息傳達(dá)或分享的目的。五是用于公共衛(wèi)生行動(dòng)。主要用于評(píng)價(jià)公共衛(wèi)生狀況，確定公共衛(wèi)生問(wèn)題或有限領(lǐng)域，評(píng)價(jià)公共衛(wèi)生項(xiàng)目，促進(jìn)醫(yī)學(xué)研究。

按照定義，如果下級(jí)單位常規(guī)上報(bào)監(jiān)測(cè)數(shù)據(jù)和資料，而上級(jí)單位被動(dòng)接受，稱為被動(dòng)監(jiān)測(cè)，根據(jù)特殊需要上級(jí)部門專門調(diào)查或要求下級(jí)單位嚴(yán)格按照規(guī)定收集資料，稱為主動(dòng)監(jiān)測(cè)。此外，為了更加清楚地了解某些疾病在不同地區(qū)、不同人群的分布以及相應(yīng)的影響因素等，根據(jù)被監(jiān)測(cè)疾病的流行特點(diǎn)，選擇若干有代表性的地區(qū)和人群，按照統(tǒng)一的監(jiān)測(cè)方案連續(xù)地開(kāi)展監(jiān)測(cè)稱之為哨點(diǎn)監(jiān)測(cè)。

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?"