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Patient‐level Factors and the Quality of Care Delivered in Pediatric Emergency Departments 下载免费PDF全文
James P. Marcin MD MPH Patrick S. Romano MD MPH Parul Dayal MS Madan Dharmar MBBS PhD James M. Chamberlain MD Nanette Dudley MD Charles G. Macias MD MPH Lise E. Nigrovic MD MPH Elizabeth C. Powell MD MPH Alexander J. Rogers MD Meridith Sonnett MD Leah Tzimenatos MD Elizabeth R. Alpern MD MSCE Rebecca Andrews‐Dickert MD Dominic A. Borgialli DO MPH Erika Sidney MD T. Charles Casper PhD J. Michael Dean MD Nathan Kuppermann MD MPH for the Pediatric Emergency Care Applied Research Network 《Academic emergency medicine》2018,25(3):301-309
Objective
Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient‐level factors.Methods
This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect.Results
In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (–0.65 points in quality, 95% confidence interval [CI] = –1.24 to –0.06) and upper respiratory symptoms (–0.68 points in quality, 95% CI = –1.30 to –0.07).Conclusion
We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.83.
Improved Survival for Rural Trauma Patients Transported by Helicopter to a Verified Trauma Center: A Propensity Score Analysis 下载免费PDF全文
Thein Hlaing Zhu MBBS FACE FRCP Lisa Hollister RN MSN Dazar Opoku MPH Samuel M. Galvagno DO PhD MS FCCM Jr. 《Academic emergency medicine》2018,25(1):44-53
Objectives
Recent studies using advanced statistical methods to control for confounders have demonstrated an association between helicopter transport (HT) versus ground ambulance transport (GT) in terms of improved survival for adult trauma patients. The aim of this study was to apply a methodologically vigorous approach to determine if HT is associated with a survival benefit for when trauma patients are transported to a verified trauma center in a rural setting.Methods
The ascertainment of trauma patients age ≥ 15 years (n = 469 cases) by HT and (n = 580 cases) by GT between 1999 and 2012 was restricted to the scene of injury in a rural area of 10 to 35 miles from the trauma center. The propensity score (PS) was determined using data including demographics, prehospital physiology, intubation, total prehospital time, and injury severity. The PS matching was performed with different calipers to select a higher percentage of matches of HT compared to GT patients. The outcome of interest was survival to discharge from hospital. Identical logistic regression analysis was done taking into account for each matched design to select an appropriate effect estimate and confidence interval (CI) controlling for initial vital signs in the emergency department, the need for urgent surgery, intensive care unit admission, and mechanical ventilation.Results
Unadjusted mortalities for HT compared to GT were 7.7 and 5.3%, respectively (p > 0.05). The adjusted rates were 4.0% for HT and 7.6% for GT (p < 0.05). In a PS well‐matched data set, HT was associated with a 2.69‐fold increase in odds of survival compared to GT patients (adjusted odds ratio = 2.69; 95% CI = 1.21–5.97).Conclusions
In a rural setting, we demonstrated improved survival associated with HT compared to GT for scene transportation of adult trauma patients to a verified Level II trauma center using an advanced methodologic approach, which included adjustment for transport distance. The implication of survival benefit to rural population is discussed. We recommend larger studies with multiple trauma systems need to be repeated using similar study methodology to substantiate our findings. 相似文献84.
Morgan R. Bobb Azeemuddin Ahmed MD MBA Paul Van Heukelom MD Rachel Tranter MPAS PA‐C Karisa K. Harland PhD MPH Brady M. Firth PhD MA Randy Fry MBA Katherine Schneider MSN RN CEN Kathryn K. Dierks DO Sarah L. Miller MD Nicholas M. Mohr MD MS 《Academic emergency medicine》2018,25(7):795-803
Objective
The objective of this study was to determine specific provider practices associated with high provider efficiency in community emergency departments (EDs).Methods
A mixed‐methods study design was utilized to identify key behaviors associated with efficiency. Stage 1 was a convenience sample of 16 participants (ED medical directors, nurses, advanced practice providers, and physicians) identified provider efficiency behaviors during semistructured interviews. Ninety‐nine behaviors were identified and distilled by a group of three ED clinicians into 18 themes. Stage 2 was an observational study of 35 providers was performed in four (30,000‐ to 55,000‐visit) community EDs during two 4‐hour periods and recorded in minute‐by‐minute observation logs. In Stage 3, each behavior or practice from Stage 1 was assigned a score within each observation period. Behaviors were tested for association with provider efficiency (relative value units/hour) using linear univariate generalized estimating equations with an identity link, clustered on ED site.Results
Five ED provider practices were found to be positively associated with efficiency: average patient load, using name of team member, conversations with health care team, visits to patient rooms, and running the board. Two behaviors, “inefficiency practices,” demonstrated significant negative correlations: non–work‐related tasks and documentation on patients no longer in the ED.Conclusions
Average patient load, running the board, conversations with team member, and using names of team members are associated with enhanced provider productivity. Identification of behaviors associated with efficiency can be utilized by medical directors, clinicians, and trainees to improve personal efficiency or counsel team members.85.
Martin Reynolds PhD Eric Sarriot MD PhD Robert Chad Swanson DO Evan Rusoja MD PhD 《Journal of evaluation in clinical practice》2018,24(3):619-628
Systems thinking and reference to complexity science have gained currency in health sector practice and research. The extent to which such ideas might represent a mere passing fad or might more usefully be mobilized to tackle wicked problems in health systems is a concern underpinning this paper. Developing the usefulness of the systems idea requires appreciating how systems ideas are used essentially as constructs conceptually bounded by practitioners. Systems are used for purposes of understanding and engaging the reality of health issues, with the intent of transforming the reality into one that is more manageable, equitable, and sustainable. We examine some manifestations of the systems idea in health practice and the traditions of systems practice that variously make use of them. This provides a platform for proposing a systems thinking in (health) practice heuristic: a learning device supporting how different tools and methods can address “wicked problems” in health praxis. The device is built on the use of “conversation” as a metaphor to help practitioners use systems ideas in tandem with existing disciplinary and professional skills and methods. We consider how the application of the heuristic requires, and helps to develop, human characteristics of humility, empathy, and recognition of fallibility. 相似文献
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Respiratory morbidity in a coffee processing workplace with sentinel obliterative bronchiolitis cases 下载免费PDF全文
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Anesthesia for subcutaneous implantable cardioverter‐defibrillator implantation: Perspectives from the clinical experience of a U.S. panel of physicians 下载免费PDF全文
Michael K. Essandoh MD George E. Mark MD Johan D. Aasbo DO Charles A Joyner MD Saumya Sharma MD Beningo F Decena MD Eric D Bolin MD Raul Weiss MD Martin C Burke DO Timothy R. McClernon PhD Emile G. Daoud MD Michael R. Gold MD PhD 《Pacing and clinical electrophysiology : PACE》2018,41(7):807-816