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Introduction

The acute surgical model has been trialled in several institutions with mixed results. The aim of this study was to determine whether the acute surgical model provides better outcomes for patients with acute biliary presentation, compared with the traditional emergency surgery model of care.

Methods

A retrospective review was carried out of patients who were admitted for management of acute biliary presentation, before and after the establishment of an acute surgical unit (ASU). Outcomes measured were time to operation, operating time, after-hours operation (6pm – 8am), length of stay and surgical complications.

Results

A total of 342 patients presented with acute biliary symptoms and were managed operatively. The median time to operation was significantly reduced in the ASU group (32.4 vs 25.4 hours, p=0.047), as were the proportion of operations performed after hours (19.5% vs 2.5%, p<0.001) and the median length of stay (4 vs 3 days, p<0.001). The median operating time, rate of conversion to open cholecystectomy and wound infection rates remained similar.

Conclusions

Implementation of an ASU can lead to objective differences in outcomes for patients who present with acute cholecystitis. In our study, the ASU significantly reduced time to operation, the number of operations performed after hours and length of stay.  相似文献   
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Interindividual variability in analgesic effects of nonsteroidal anti‐inflammatory drugs prescribed for sickle cell disease (SCD) pain is attributed to polymorphisms in the CYP2C8 and CYP2C9 enzymes. We described CYP2C8 and CYP2C9 genotype/phenotype profiles and frequency of emergency department (ED) visits for pain management in an African American SCD patient cohort. DNA from 165 unrelated patients was genotyped for seven CYP2C8 and 15 CYP2C9 alleles using the iPLEX ADME PGx multiplexed panel. CYP2C8*1 (0.806),*2 (0.164), *3 (0.018), and *4 (0.012) alleles were identified. Genotype frequencies were distributed as homozygous wild type (66.7%), heterozygous (27.8%), and homozygous variant/compound heterozygous (5.4%), respectively. CYP2C9*1 (0.824), *2 (0.027), *3 (0.012), *5 (0.009), *6 (0.009), *8 (0.042), *9 (0.061), and *11(0.015) were observed with extensive (68.5%), intermediate (18.1%) and poor predicted metabolizers (0.6%), respectively. Fifty‐two and 55 subjects, respectively had at least one variant CYP2C8 or CYP2C9 allele. Although the distribution of the CYP2C9 (p = 0.0515) phenotypes was marginally significantly in high and low ED users; some CYP2C8 and CYP2C9 allelic combinations observed in 15.2% (25) of the cohort are associated with higher risks for analgesic failure. CYP2C8 and CYP2C9 preemptive genotyping could potentially enable clinicians to identify patients with impaired metabolic phenotypes.  相似文献   
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Patient safety culture is a critical component of modern health care. However, the high‐paced, unpredictable nature of the emergency department (ED) environment may impact adversely on it. The aim of this paper is to explore the concept of patient safety culture as it may apply to emergency health care, and to propose a conceptual framework that could form the basis for interventions designed to improve it. This is a systematic review of the literature. A search was undertaken of common electronic bibliographic databases using key words such as safety culture, safety climate, and Emergency Department. Articles were analysed for consistent themes with the aim to construct a conceptual framework. Ten articles met the inclusion criteria that specifically examined safety culture in the ED. Synthesis of the literature resulted in the emergence of three overarching themes of ED practice found to impact on safety culture in the ED. These were the dimensions of patient safety culture, the factors influencing it, and the interventions for improving it. A conceptual framework was constructed that identifies elements that significantly impact the patient safety culture in the ED. This framework may assist managers and researchers to take a comprehensive approach to build an effective safety culture in ED setting.  相似文献   
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Methods for measuring onset latency contrasts are evaluated against a new method utilizing the dynamic time warping (DTW) algorithm. This new method allows latency to be measured across a region instead of single point. We use computer simulations to compare the methods’ power and Type I error rates under different scenarios. We perform per‐participant analysis for different signal‐to‐noise ratios and two sizes of window (broad vs. narrow). In addition, the methods are tested in combination with single‐participant and jackknife average waveforms for different effect sizes, at the group level. DTW performs better than the other methods, being less sensitive to noise as well as to placement and width of the window selected.  相似文献   
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The series of events leading to tertiary lymphoid organ (TLO) formation in mucosal organs following tissue damage remain unclear. Using a virus-induced model of autoantibody formation in the salivary glands of adult mice, we demonstrate that IL-22 provides a mechanistic link between mucosal infection, B-cell recruitment, and humoral autoimmunity. IL-22 receptor engagement is necessary and sufficient to promote differential expression of chemokine (C-X-C motif) ligand 12 and chemokine (C-X-C motif) ligand 13 in epithelial and fibroblastic stromal cells that, in turn, is pivotal for B-cell recruitment and organization of the TLOs. Accordingly, genetic and therapeutic blockade of IL-22 impairs and reverses TLO formation and autoantibody production. Our work highlights a critical role for IL-22 in TLO-induced pathology and provides a rationale for the use of IL-22–blocking agents in B-cell–mediated autoimmune conditions.Tertiary lymphoid organs (TLOs) are organized clusters of immune cells that preferentially form in autoimmune diseases such as Sjogren’s syndrome and Hashimoto thyroiditis (1). TLOs’ cellular compartments, spatial organization, vasculature, and function are similar to those of secondary lymphoid organs (SLOs), providing a local hub for autoreactive B-cell proliferation and affinity maturation. TLOs appear to contribute to disease progression and to the emergence of malignant B clones responsible for lymphoma development (2). Within TLOs, the ectopic expression of lymphoid chemokines has been shown to correlate with the size or degree of organization of lymphoid aggregates and with the production of autoantibodies (3, 4). In the case of malignant transformation, lymphoid chemokine expression increases during disease progression (5). The pathways regulating chemokine expression in SLOs during embryonic life have been largely described and mainly involve the engagement of lymphotoxin β receptor on a family of gp38+ lymphoid tissue-organizer stromal cells (6). At sites of TLO formation, lymphotoxin and lymphotoxin-producing cells appear to be dispensable for the early production of lymphoid chemokines required during SLO formation, raising the possibility that signals other than lymphotoxin can regulate the formation of TLOs, stimulating the production of lymphoid chemokines during inflammation (7, 8). Some of these signals have been identified in the family of the IL-23/IL-17 cytokines (9), but other cytokines have been advocated in TLO formation; thus different molecules may play differential roles depending on site and nature of the etiological agent (10).IL-22, a member of the IL-10 cytokine superfamily, regulates mucosal responses to danger and wound healing (11). IL-22 promotes tissue repair, inducing epithelial cell proliferation and survival, in both physiological and pathological conditions (1215). Recently, an association between IL-22 expression and autoimmune B-cell activation has been proposed (16). In Sjogren’s syndrome, serum levels of IL-22 correlate with clinical manifestations including autoantibody production (17). Furthermore, B-cell–depleting treatment modulates salivary gland expression of IL-22, thus suggesting a potential functional relationship between IL-22 expression, B-cell infiltration, and local pathology (18). Previously we have demonstrated that direct cannulation of murine salivary glands with a replication-deficient adenovirus induces the formation of organized T-cell and B-cell aggregates, local expression of lymphoid chemokines, and the enzyme aicda [activation-induced cytidine deaminase (AID)] required for affinity maturation and isotype switching in B cells (19). Exploiting this model, we tested the hypothesis that IL-22 is involved in the generation of a humoral response within the TLOs (19). Here we demonstrate that early expression of IL-22 is instrumental for lymphoid chemokine production by stromal cells that, in turn, regulates B-cell aggregation. This work highlights a novel role for IL-22 in lymphoid chemokine expression and provides a mechanistic link between deranged mucosal responses and autoantibody production.  相似文献   
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