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991.
Thomas M. Kaffenberger MD Raj C. Dedhia MD MS Hannah L. Schwarzbach BA Leila J. Mady MD PhD MPH Stella E. Lee MD 《International forum of allergy & rhinology》2018,8(5):563-570
Background
Skin‐prick testing (SPT), in vitro testing (IVT), and intradermal‐dilutional testing (IDT) are methods to detect patient sensitivities to specific allergens and direct immunotherapy dosing. We used objective and subjective measures of improvement to compare outcomes based on test method.Methods
Patients underwent 1 of 3 protocols: SPT, screening SPT followed by IDT, or IVT. We used institution billing data to do a cost analysis of these tests. The time to maintenance (TTM) therapy was analyzed and patients were stratified into high and low reactors. The Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) was used to quantify symptoms pre‐maintenance and post‐maintenance.Results
Of 177 patients (SPT, n = 40; IVT, n = 91; IDT, n = 46), 115 (SPT, n = 35; IVT, n = 39; IDT, n = 41) were high reactors. Out of 90 patients (SPT, n = 17; IVT, n = 37; IDT, n = 36) reaching maintenance, 58 were high reactors (SPT, n = 15; IVT, n = 12; IDT, n = 31). Overall, SPT, IVT, and IDT median TTM were 542, 329, and 578.5 days, respectively. IDT TTM was shorter compared to IVT overall and in high reactors (hazard ratio [HR] = 1.91, p = 0.02; HR = 2.12, p = 0.03), but was not significant compared to SPT high reactors (p = 0.33). The IDT cost was $62.66, translating to an incremental cost‐effectiveness ratio of $0.23 per day of shortened TTM. Median RQLQ change for the SPT, IVT, and IDT groups was 6.5, 1, and 1.5, respectively, but was not significant (p = 0.60).Conclusion
IDT reached maintenance immunotherapy quicker than IVT but there was no difference compared to SPT. TTM did not correlate with improvements in patient symptoms between testing methods. This study represents a novel comparison of outcomes based on initial allergy testing method.992.
Dr. Christopher A. Smith MD Avery S. Hart MD Laura S. Sadowski MD MPH Janet Riddle MD Arthur T. Evans MD MPH Peter M. Clarke MD Pamela S. Ganschow MD Ellen Mason MD Winston Sequeira MD Yue Wang PhD 《Journal of general internal medicine》2006,21(1):1-6
OBJECTIVE: To determine if structured teaching of bedside cardiac examination skills improves medical residents’ examination technique
and their identification of key clinical findings.
DESIGN: Firm-based single-blinded controlled trial.
SETTING: Inpatient service at a university-affiliated public teaching hospital.
PARTICIPANTS: Eighty Internal Medicine residents.
METHODS: The study assessed 2 intervention groups that received 3-hour bedside teaching sessions during their 4-week rotation using
either: (1) a traditional teaching method, “demonstration and practice” (DP) (n=26) or (2) an innovative method, “collaborative discovery” (CD) (n=24). The control group received their usual ward teaching sessions (n=25). The main outcome measures were scores on examination technique and correct identification of key clinical findings on
an objective structured clinical examination (OSCE).
RESULTS: All 3 groups had similar scores for both their examination technique and identification of key findings in the preintervention
OSCE. After teaching, both intervention groups significantly improved their technical examination skills compared with the
control group. The increase was 10% (95% confidence interval [CI] 4% to 17%) for CD versus control and 12% (95% CI 6% to 19%)
for DP versus control (both P<.005) equivalent to an additional 3 to 4 examination skills being correctly performed. Improvement in key findings was limited
to a 5% (95% CI 2% to 9%) increase for the CD teaching method, CD versus control P=.046, equivalent to the identification of an additional 2 key clinical findings.
CONCLUSIONS: Both programs of bedside teaching increase the technical examination skills of residents but improvements in the identification
of key clinical findings were modest and only demonstrated with a new method of teaching.
The authors have no conflicts of interest to declare for this article.
Financial support: This study was performed as part of a Faculty Development Program in Clinical Epidemiology and Research
sponsored by the Collaborative Research Unit of John H. Stroger Jr. Hospital of Cook County i Rush Medical College. 相似文献
993.
Nayahmka McGriff-Lee PharmD Sophia N. Kalantaridou MD PhD Frank Pucino PharmD BCPS FASHP FDPGEC Karim Anton Calis PharmD MPH BCPS BCNPS FASHP FCCP 《Clinical reviews in bone and mineral metabolism》2005,3(1):51-66
Although the beneficial effects of estrogen on bone have been proven in multiple well-designed clinical trials, with respect
to testosterone and androgens, the data are less definitive. Testosterone appears to have a role in the development and maintenance
of bone mass; however, the mechanism by which androgens exert their effects on bone is still not clearly understood. Despite
the increasing use of testosterone supplementation in men and women for the prevention and treatment of osteoporosis, in sufficient
evidence exists to support the widespread use of these agents for this indication at this time. The data supporting the beneficial
effects of testosterone on bone mineral density are more convincing in hypogonadal men than in men with normal testosterone
levels, or in women. The transdermal route of administration is often preferred for testosterone therapy because it avoids
the first-pass metabolism associated with oral formulations and the pain experienced with intramuscular injections. Other
androgens, including an abolic steroids and dihydroepiandrosterone, have also been used. In addition to monitoring for therapeutic
response on initiation of androgen therapy, assessment for potential adverse events should be implemented. This should include
assessment for adverse effects on the liver and alterations in the lipid profile in both men and women. Men should also be
monitored for prostate growth, gynecomastia, priapism, decreased libido, and erythrocytosis, whereas women should be monitored
for virilizing effects. Ongoing research into the pathophysiology and clinical effects of testosterone on bone will provide
more insights regarding the utility of androgens in these populations. 相似文献
994.
Kao AC Zaslavsky AM Green DC Koplan JP Cleary PD 《Journal of general internal medicine》2001,16(3):181-188
OBJECTIVE: There is increasing public discussion of the value of disclosing how physicians are paid. However, little is known about patients' awareness of and interest in physician payment information or its potential impact on patients' evaluation of their care. DESIGN: Cross-sectional survey SETTING: Managed care and indemnity plans of a large, national health insurer. PARTICIPANTS: Telephone interviews were conducted with 2,086 adult patients in Atlanta, Ga; Baltimore, Md/Washington DC; and Orlando, Fla (response rate, 54%). MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to assess perceptions of their physicians' payment method, preference for disclosure, and perceived effect of different financial incentives on quality of care. Non-managed fee-for-service patients (44%) were more likely to correctly identify how their physicians were paid than those with salaried (32%) or capitated (16%) physicians. Just over half (54%) wanted to be informed about their physicians' payment METHOD: Patients of capitated and salaried physicians were as likely to want disclosure as patients of fee-for-service physicians. College graduates were more likely to prefer disclosure than other patients. Many patients (76%) thought a bonus paid for ordering fewer than the average number of tests would adversely affect the quality of their care. About half of the patients (53%) thought a particular type of withhold would adversely affect the quality of their care. White patients, college graduates, and those who had higher incomes were more likely to think that these types of bonuses and withholds would have a negative impact on their care. Among patients who believed that these types of bonuses adversely affected care, those with non-managed fee-for-service insurance and college graduates were more willing to pay a higher deductible or co-payment in order to get tests that they thought were necessary. CONCLUSIONS: Most patients were unaware of how their physicians are paid, and only about half wanted to know. Most believed that bonuses or withholds designed to reduce the use of services would adversely affect the quality of their care. Lack of knowledge combined with strong attitudes about various financial incentives suggest that improved patient education could clarify patient understanding of the nature and rationale for different types of incentives. More public discussion of this important topic is warranted. 相似文献
995.
Posttraumatic Stress and Complicated Grief in Family Members of Patients in the Intensive Care Unit
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Background Family members of patients in intensive care units (ICUs) are at risk for mental health morbidity both during and after a
patient’s ICU stay.
Objectives To determine prevalences of and factors associated with anxiety, depression, posttraumatic stress and complicated grief in
family members of ICU patients.
Design Prospective, longitudinal cohort study.
Participants Fifty family members of patients in ICUs at a large university hospital participated.
Measurements We used the Control Preferences Scale to determine participants’ role preferences for surrogate decision-making. We used the
Hospital Anxiety and Depression Scale, Impact of Event Scale, and Inventory of Complicated Grief to measure anxiety and depression
(at enrollment, 1 month, 6 months), posttraumatic stress (6 months), and complicated grief (6 months).
Results We interviewed all 50 participants at enrollment, 39 (78%) at 1 month, and 34 (68%) at 6 months. At the three time points,
anxiety was present in 42% (95% CI, 29–56%), 21% (95% CI, 10–35%), and 15% (95% CI, 6–29%) of participants. Depression was
present in 16% (95% CI, 8–28%), 8% (95% CI, 2–19%), and 6% (95% CI, 1–18%). At 6 months, 35% (95% CI, 21–52%) of participants
had posttraumatic stress. Of the 38% who were bereaved, 46% (95% CI, 22–71%) had complicated grief. Posttraumatic stress was
not more common in bereaved than nonbereaved participants, and neither posttraumatic stress nor complicated grief was associated
with decision-making role preference or with anxiety or depression during the patient’s ICU stay.
Conclusions Symptoms of anxiety and depression diminished over time, but both bereaved and nonbereaved participants had high rates of
posttraumatic stress and complicated grief. Family members should be assessed for posttraumatic stress and complicated grief. 相似文献
996.
997.
Jessica Roberts Williams PhD MPH RN Stephen J. Tregear DPhil Tracy Dusablon PhD Lizbeth E. Caceda-Castro MEd Kristin J. Miller MSW Gary Hill PhD Kevin D. Hennessy PhD 《The journal of behavioral health services & research》2014,41(3):258-275
Increased efforts in comparative effectiveness research (CER) (comparing various health care intervention and treatment options) are being used to inform health care delivery. While CER research itself is an important step in developing best practices in health care, it is not enough to ensure success. The knowledge must also be successfully disseminated to increase adoption and implementation of practices. To ensure the greatest benefits of successful interventions, it is essential to understand which dissemination strategies are effective and under what conditions. This article provides the background and methodology used in a large-scale, 2-year study aimed at determining how knowledge gained from CER research may be most effectively disseminated to those responsible for delivering behavioral health services. The study takes an important step toward addressing the gaps in dissemination and translation of CER. 相似文献
998.
Jennifer E. Hettema PhD Denise Ernst PhD Jessica Roberts Williams PhD MPH RN Kristin J. Miller MSW 《The journal of behavioral health services & research》2014,41(3):324-336
In addition to its clinical efficacy as a communication style for strengthening motivation and commitment to change, motivational interviewing (MI) has been hypothesized to be a potential tool for facilitating evidence-based practice adoption decisions. This paper reports on the rationale and content of MI-based implementation coaching Webinars that, as part of a larger active dissemination strategy, were found to be more effective than passive dissemination strategies at promoting adoption decisions among behavioral health and health providers and administrators. The Motivational Interviewing Treatment Integrity scale (MITI 3.1.1) was used to rate coaching Webinars from 17 community behavioral health organizations and 17 community health centers. The MITI coding system was found to be applicable to the coaching Webinars, and raters achieved high levels of agreement on global and behavior count measurements of fidelity to MI. Results revealed that implementation coaches maintained fidelity to the MI model, exceeding competency benchmarks for almost all measures. Findings suggest that it is feasible to implement MI as a coaching tool. 相似文献
999.
1000.
José Joaquín Mira PhD Mercedes Guilabert PhD Virtudes Pérez‐Jover PhD Susana Lorenzo MD MPH PhD 《Health expectations》2014,17(6):826-839