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Benjamin K. Poulose Joan Kaiser William C. Beck Pearlie Jackson William H. Nealon Kenneth W. Sharp Michael D. Holzman 《Surgical endoscopy》2013,27(11):4119-4123
Background
Percutaneous endoscopic gastrostomy (PEG) remains a mainstay of enteral access. Thirty-day mortality for PEG has ranged from 16 to 43 %. This study aims to discern patient groups that demonstrate limited survival after PEG placement. The Enterprise Data Warehouse (EDW) concept allows an efficient means of integrating administrative, clinical, and quality-of-life data. On the basis of this concept, we developed the Vanderbilt Procedural Outcomes Database (VPOD) and analyzed these data for evaluation of post-PEG mortality over time.Methods
Patients were identified using the VPOD from 2008 to 2010 and followed for 1 year after the procedure. Patients were categorized according to common clinical groups for PEG placement: stroke/CNS tumors, neuromuscular disorders, head and neck cancers, other malignancies, trauma, cerebral palsy, gastroparesis, or other indications for PEG. All-cause mortality at 30, 60, 90, 180, and 360 days was determined by linking VPOD information with the Social Security Death Index. Chi-square analysis was used to determine significance across groups.Results
Nine hundred fifty-three patients underwent PEG placement during the study period. Mortality over time (30-, 60-, 90-, 180-, and 360-day mortality) was greatest for patients with malignancies other than head and neck cancer (29, 45, 57, 66, and 72 %) and least for cerebral palsy or patients with gastroparesis (7 % at all time points). Patients with neuromuscular disorders had a similar mortality curve as head and neck cancer patients. Stroke/CNS tumor patients and patients with other indications had the second highest mortality, while trauma patients had low mortality.Conclusions
PEG mortality was much higher in patients with malignancies other than head and neck cancer compared to previously published rates. PEG should be used with great caution in this and other high-risk patient groups. This study demonstrates the power of an EDW-based database to evaluate large numbers of patients with clinically meaningful results. 相似文献994.
Leigh A. Humphries Jonathan M. Hernandez Whalen Clark Kenneth Luberice Sharona B. Ross Alexander S. Rosemurgy 《Surgical endoscopy》2013,27(5):1537-1545
Background
Although laparoscopic fundoplication effectively alleviates gastroesophageal reflux disease (GERD) in the great majority of patients, some patients remain dissatisfied after the operation. This study was undertaken to report the outcomes of these patients and to determine the causes of dissatisfaction after laparoscopic fundoplication.Methods
All patients undergoing laparoscopic fundoplication in the authors’ series from 1992 to 2010 were evaluated for frequency and severity of symptoms before and after laparoscopic fundoplication, and their experiences were graded from “very satisfying” to “very unsatisfying.” Objective outcomes were determined by endoscopy, barium swallow, and pH monitoring. Primary complaints were derived from postoperative surveys. Median data are reported.Results
Of the 1,063 patients undergoing laparoscopic fundoplication, 101 patients reported dissatisfaction after the procedure. The follow-up period was 33 months. The dissatisfied patients (n = 101) were more likely than the satisfied patients to have postoperative complications (9 vs 4 %; p < 0.05) and to have undergone a prior fundoplication (22 vs 11 %; p < 0.05). For the dissatisfied patients, heartburn decreased in frequency and severity after fundoplication (p < 0.05) but remained notable. Also for the dissatisfied patients, new symptoms (gas bloat/dysphagia) were the most prominent postoperative complaint (59 %), followed by symptom recurrence (23 %), symptom persistence (4 %), and the overall experience (14 %). Primary complaints of new symptoms were most common within the first year of follow-up assessment and less frequent thereafter. Primary complaints of recurrent symptoms generally occurred more than 1 year after fundoplication.Conclusions
Dissatisfaction is uncommon after laparoscopic fundoplication. New symptoms, such as dysphagia and gas/bloating, are primary causes of dissatisfaction despite general reflux alleviation among these patients. New symptoms occur sooner after fundoplication than recurrent symptoms and may become less common with time. 相似文献995.
Young Hwii Ko Rafael F. Coelho Ananthakrishnan Sivaraman Oscar Schatloff Sanket Chauhan Haidar M. Abdul-Muhsin Rair Jose Valero Carrion Kenneth J. Palmer Jun Cheon Vipul R. Patel 《European urology》2013
Background
Although the retrograde approach to nerve sparing (NS) aimed at maximizing NS during robot-assisted radical prostatectomy (RARP) has been described, its significant benefits compared to the antegrade approach have not yet been investigated.Objective
To evaluate the impact of NS approaches on perioperative, pathologic, and functional outcomes.Design, setting, and participants
Five hundred one potent (Sexual Health Inventory for Men [SHIM] score >21) men underwent bilateral full NS and were followed up for a minimum of 1 yr. After propensity score matching, 344 patients were selected and were then categorized into two groups.Surgical procedure
RARP with antegrade NS (n = 172) or RARP with retrograde NS (n = 172).Outcome measurements and statistical analysis
Functional outcomes were assessed using validated questionnaires. Multivariable logistic regression models were applied.Results and limitations
Positive margin rates were similar (11.1% vs 6.9%; p = 0.192), and no correlation with the NS approach was found on regression analysis. At 3, 6, and 9 mo, the potency rate was significantly higher in the retrograde approach (65% vs 80.8% and 72.1% vs 90.1% and 85.3% vs 92.9%, respectively). The multivariable model indicated that the NS approach was an independent predictor for potency recovery at 3, 6, and 9 mo, along with age, gland size, and hyperlipidemia. After adjusting for these predictors, the hazard ratio (HR) for the retrograde relative to the antegrade approach was 2.462 (95% confidence interval [CI], 1.482–4.089; p = 0.001) at 3, 4.024 (95% CI, 2.171–7.457; p < 0.001) at 6, and 2.145 (95% CI, 1.019–4.514; p = 0.044) at 9 mo. Regarding continence, the recovery rates at each time point and the mean time to regaining it were similar, and the method of NS had no effect on multivariable analysis. The absence of randomization is a major limitation of this study.Conclusions
In patients with normal erectile function who underwent bilateral full NS, a retrograde NS approach facilitated early recovery of potency compared to that with an antegrade NS approach without compromising cancer control. 相似文献996.
Henrik Palm Eva Posner Hans-Ulrik Ahler-Toftehøj Peter Siesing Silas Gylvin Tobias Aasvang Kim Holck Kenneth Brian Holtz 《International orthopaedics》2013,37(6):1121-1126
Purpose
Hip fracture treatment is controversial, with high complication rates. An algorithm for hip fracture surgery has shown reduced reoperation rates, but choice of implant is based on the commonly used fracture classifications, which were previously evaluated to be unreliable. The purpose of this study was to investigate the reliability of the algorithm.Methods
From two hospitals, four observers (orthopaedic consultant, fellow, resident and intern) used the algorithm to classify into 15 hip fracture types [Garden type I–IV femoral neck including posterior tilt, vertical femoral neck, basocervical and Arbeitsgemeinschaft für Osteosynthesefragen (AO)-31 A1.1 to A3.3 trochanteric fractures] and to choose between five surgical procedures [parallel implants, prosthesis, two-or four-hole sliding hip screw (SHS) and intermedullary (IM) nail]. After individual assessment, each hospital made a consensus decision. Observations were performed twice, ten weeks apart, on pelvic, anteroposterior (AP) and axial X-rays from 100 consecutive patients.Results
For fracture classification, mean kappa values were 0.60 for intra and 0.62 for interobserver variation, with interobserver variation between hospitals at 0.65. For posterior tilt, mean intraclass correlation coefficient was 0.91 for intra and 0.87 for interobserver variation. For choice of implant type, mean kappa values were 0.86 for both intra and interobserver variation. The two hospital consensus decisions chose same implant in 91 of 100 patients, giving a kappa value at 0.88.Conclusion
Although hip fracture classification confirmed to be somewhat unreliable in this study, posterior tilt measurement and subsequent choice of implant type by the algorithm was found to be reliable, which opens up the possibility for a more standardized treatment of hip fracture patients between hospitals. 相似文献997.
998.
Benjamin P Sinder Mary M Eddy Michael S Ominsky Michelle S Caird Joan C Marini Kenneth M Kozloff 《Journal of bone and mineral research》2013,28(1):73-80
Osteogenesis imperfecta (OI) is a genetic bone dysplasia characterized by osteopenia and easy susceptibility to fracture. Symptoms are most prominent during childhood. Although antiresorptive bisphosphonates have been widely used to treat pediatric OI, controlled trials show improved vertebral parameters but equivocal effects on long‐bone fracture rates. New treatments for OI are needed to increase bone mass throughout the skeleton. Sclerostin antibody (Scl‐Ab) therapy is potently anabolic in the skeleton by stimulating osteoblasts via the canonical wnt signaling pathway, and may be beneficial for treating OI. In this study, Scl‐Ab therapy was investigated in mice heterozygous for a typical OI‐causing Gly→Cys substitution in col1a1. Two weeks of Scl‐Ab successfully stimulated osteoblast bone formation in a knock‐in model for moderately severe OI (Brtl/+) and in WT mice, leading to improved bone mass and reduced long‐bone fragility. Image‐guided nanoindentation revealed no alteration in local tissue mineralization dynamics with Scl‐Ab. These results contrast with previous findings of antiresorptive efficacy in OI both in mechanism and potency of effects on fragility. In conclusion, short‐term Scl‐Ab was successfully anabolic in osteoblasts harboring a typical OI‐causing collagen mutation and represents a potential new therapy to improve bone mass and reduce fractures in pediatric OI. © 2013 American Society for Bone and Mineral Research 相似文献
999.
Zhican Wang Yvonne S Lin Leslie J Dickmann Emma‐Jane Poulton David L Eaton Johanna W Lampe Danny D Shen Connie L Davis Margaret C Shuhart Kenneth E Thummel 《Journal of bone and mineral research》2013,28(5):1101-1116
Long‐term therapy with certain drugs, especially cytochrome P450 (P450; CYP)‐inducing agents, confers an increased risk of osteomalacia that is attributed to vitamin D deficiency. Human CYP24A1, CYP3A4, and CYP27B1 catalyze the inactivation and activation of vitamin D and have been implicated in the adverse drug response. In this study, the inducibility of these enzymes and monohydroxylation of 25‐hydroxyvitamin D3 (25OHD3) were evaluated after exposure to P450‐inducing drugs. With human hepatocytes, treatment with phenobarbital, hyperforin, carbamazepine, and rifampin significantly increased the levels of CYP3A4, but not CYP24A1 or CYP27B1 mRNA. In addition, rifampin pretreatment resulted in an 8‐fold increase in formation of the major metabolite of 25OHD3, 4β,25(OH)2D3. This inductive effect was blocked by the addition of 6′,7′‐dihydroxybergamottin, a selective CYP3A4 inhibitor. With human renal proximal tubular HK‐2 cells, treatment with the same inducers did not alter CYP3A4, CYP24A1, or CYP27B1 expression. 24R,25(OH)2D3 was the predominant monohydroxy metabolite produced from 25OHD3, but its formation was unaffected by the inducers. With healthy volunteers, the mean plasma concentration of 4β,25(OH)2D3 was increased 60% (p < 0.01) after short‐term rifampin administration. This was accompanied by a statistically significant reduction in plasma 1α,25(OH)2D3 (?10%; p = 0.03), and a nonsignificant change in 24R,25(OH)2D3 (?8%; p = 0.09) levels. Further analysis revealed a negative correlation between the increase in 4β,25(OH)2D3 and decrease in 1α,25(OH)2D3 levels. Examination of the plasma monohydroxy metabolite/25OHD3 ratios indicated selective induction of the CYP3A4‐dependent 4β‐hydroxylation pathway of 25OHD3 elimination. These results suggest that induction of hepatic CYP3A4 may be important in the etiology of drug‐induced osteomalacia. © 2013 American Society for Bone and Mineral Research. 相似文献
1000.