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101.
Kirsty Boyd Bruce Mason Marilyn Kendall Stephen Barclay David Chinn Keri Thomas Aziz Sheikh Scott A Murray 《The British journal of general practice》2010,60(581):e449-e458
Background
Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging.Aim
To assess the feasibility of implementing advance care planning in UK primary care.Design of study
Mixed methods evaluation of a pilot educational intervention.Setting
Four general practices in south-east Scotland.Method
Interviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK.Results
End-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a ‘good death’. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of ‘tick-box’ approach. Following the workshop, participants'' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care.Conclusion
A clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes. 相似文献102.
Anil Kumar Wilbert S. Aronow Margelusa Alexa Ritu Gothwal Stephen Jesmajian Bharat Bhushan Praveen Gaba James Catevenis 《Archives of Medical Science》2010,6(2):188-191
Introduction
The prevalence of use of any advance directives was 26% in 112 patients hospitalized in a cardiac care unit (CCU)/intensive care unit (ICU) in an academic medical center.Material and methods
We investigated in 2 community hospitals the prevalence of use of advance directives (AD), health care proxy (HCP), legal guardian (LG), and living will (LW) in 512 patients hospitalized in a CCU/ ICU approached for AD and HCP.Results
The use of AD was 22%, of HCP was 19%, of LG was 16%, and of LW was 5%.Conclusions
The use of AD was 22%, of HCP was 19%, of LG was 16%, and of LW was 5% in patients hospitalized in a CCU/ICU. Educational programs on use of AD and of HCP need to be part of cardiovascular training programs and of cardiovascular continuing medical education. 相似文献103.
104.
105.
《Journal of the American Medical Directors Association》2020,21(5):647-652
ObjectivesLong-term care (LTC) is an important setting for goals of care (GoC) discussions. Understanding clinician barriers to GoC discussions could identify opportunities for LTC-specific interventions to improve quantity and quality of GoC discussions in the context of serious illness.DesignA multicenter, cross-sectional survey study.Setting and Participants1184 LTC clinicians from 34 Ontario LTC homes were invited to participate.MeasuresThe questionnaire assessed (1) clinician barriers related to the LTC resident power of attorney (POA), the health care provider, and the health care system; (2) willingness to engage in GoC discussions; and (3) suggestions to address identified barriers. Responses were rated on a 7-point scale (1 = extremely unimportant/unwilling, 7 = extremely important/willing). A linear mixed-effects model determined significance between mean importance ratings for each barrier and the willingness to engage in GoC discussion between physicians and nurses. A simple content analysis was performed on written suggestions to address GoC discussion barriers.ResultsThe overall response rate was 49% (581/1184). The top 3 rated barriers were (1) POA's difficulty accepting their loved one's poor prognosis, (2) POA's difficulty understanding the limitations and complications of life-sustaining therapies, and (3) lack of adequate documentation of prior discussions with LTC resident or POA. Barriers related to the health care provider, and the health care system, were deemed statistically more important by nurses. LTC physicians were more willing to exchange information, be a decision coach, and participate in the final decision than nurses. Suggestions to improve GoC discussions include a dedicated team to have these conversations in LTC, and updating policies to mandate and standardize these conversations at all family meetings.Conclusions and ImplicationsThis study has identified key LTC clinician–identified barriers to GoC discussions. Developing targeted interventions to these barriers could be the foundation for developing new interventions that support high-quality GoC discussions. 相似文献
106.
Symptom burden, quality of life, advance care planning and the potential value of palliative care in severely ill haemodialysis patients. 总被引:7,自引:4,他引:3
Steven D Weisbord Sharon S Carmody Frank J Bruns Armando J Rotondi Lewis M Cohen Mark L Zeidel Robert M Arnold 《Nephrology, dialysis, transplantation》2003,18(7):1345-1352
BACKGROUND: There has been little research on the potential value of palliative care for dialysis patients. In this pilot study, we sought (i) to identify symptom burden, health-related quality of life (HRQoL) and advance directives in extremely ill haemodialysis patients to determine their suitability for palliative care and (ii) to determine the acceptability of palliative care to patients and nephrologists. METHODS: Nineteen haemodialysis patients with modified Charlson co-morbidity scores of > or =8 were recruited. Each completed surveys to assess symptom burden, HRQoL and prior advance care planning. Palliative care specialists then visited patients twice and generated recommendations. Patients again completed the surveys, and dialysis charts were reviewed to assess nephrologists' (i) compliance with recommendations and (ii) documentation of symptoms reported by patients on the symptom assessment survey. Patients and nephrologists then completed surveys assessing their satisfaction with palliative care. RESULTS: Patients reported 10.5 symptoms, 40% of which were noted by nephrologists in patients' charts. HRQoL was significantly impaired. Thirty-two percent of patients had living wills. No differences were observed in symptoms, HRQoL or number of patients establishing advance directives as a result of the intervention. Sixty-eight percent of patients and 76% of nephrologists rated the intervention worthwhile. CONCLUSIONS: Extremely ill dialysis patients have marked symptom burden, considerably impaired HRQoL and frequently lack advance directives, making them appropriate candidates for palliative care. Patients and nephrologists perceive palliative care favourably despite its lack of effect in this study. A more sustained palliative care intervention with a larger sample size should be attempted to determine its effect on the care of this population. 相似文献
107.
Vig EK Sudore RL Berg KM Fromme EK Arnold RM 《Journal of pain and symptom management》2011,42(5):777-782
Clinicians may feel conflicted when a patient’s legal decision maker is making decisions that seem inconsistent with a patient’s living will. We provide evidence-based information to help clinicians consider whether a surrogate’s inconsistent decisions are ethically appropriate. Surrogates are not flawless translators of their loved one’s preferences; they are influenced by their own hopes and the current clinical context. Patients may be aware of this, are often concerned about burdening their loved ones, and often grant their surrogates leeway in interpreting their wishes. When appropriate, clinicians should respect surrogates’ interpretations of patient values and take steps to decrease surrogate stress during the decision-making process. Finally, if clinicians are cognizant of their own values and preferences, they may recognize how these may affect their responses to certain clinical cases. 相似文献
108.
Kim MM Scheyett AM Elbogen EB Van Dorn RA McDaniel LA Swartz MS Swanson JW Ferron J 《Community mental health journal》2008,44(1):28-46
Studies have begun to explore provider attitudes’ toward psychiatric advance directives (PADs) and how those attitudes are
related to provider characteristics. The study gathered attitudinal data from a sample of 193 social workers serving mentally
ill adults. Social workers with pro-healthcare power of attorney (HCPA) attitudes were likely to have prior experience with
an HCPA and to believe that involuntary treatment violates the NASW Code of Ethics. Social workers are more favorable of HCPAs
than advance instructions. The findings suggest that clinical experiences with PADs may positively impact social worker’s
perceptions of the law. 相似文献
109.
Salvatore P Ghidini S Zita G De Panfilis C Lambertino S Maggini C Baldessarini RJ 《Bipolar disorders》2008,10(2):256-265
OBJECTIVES: Most physiological indicators of bipolar disorder (BPD) reflect current acute illness, and rarely have proved to be state-independent. Activity rhythms are highly abnormal in acute phases of BPD; we compared circadian activity rhythms in BPD I patients during ill and recovered states to those of normal controls to test the hypothesis that some abnormalities may persist. METHODS: We compared 36 adult DSM-IV BPD I patients during acute mania or mixed states, and during full and sustained clinical recovery, to 32 healthy controls of similar age and sex distribution, using wrist-worn, piezoelectric actigraphic monitoring for 72 h and computed cosinor analysis of circadian activity rhythms. RESULTS: We verified expected major differences between manic or mixed-state BPD I patients and matched normal controls, including phase advances averaging 2.1 h in ill BPD I patients and 1.8 h in recovered patients. Moreover, recovered BPD patients differed highly significantly from controls in several measures, including acrophase advance, higher percentage of nocturnal sleep, and lower average daily activity (mesor). Actigraphic measures among recovered BPD patients were independent of ratings of mania (on the Young Mania Rating Scale), depression (on the Hamilton Depression Rating Scale), or rating-scale scored subjective distress, as well as the type and dose of concurrent psychotropic medication. CONCLUSIONS: These findings suggest that abnormal activity rhythms, including sustained phase advances, may represent enduring (trait) characteristics of BPD patients even during clinical recovery. If verified, such indices may be useful in supporting diagnoses and as an objective phenotype for genetic or other biological studies. 相似文献
110.