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BACKGROUND: The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the \"computerized firm system\" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study. METHODS: A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care \"firms\") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled \"firm trials\" in a matter of months at low cost. RESULTS: During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions. CONCLUSIONS: The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.  相似文献   
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The collapse mechanism of the shaped charge jet prevents the formation of a jet, the segments of which move in a straight line with absolute accuracy, even under the assumption that the shaped charge is ideally symmetrical. This is a result of the fact that the jet break-up mechanism already starts at the collapse stage, in which the liner material has a big transversal velocity component. A model for calculating the distribution of the angle by which the jet segments' direction of movement deviates from the shaped charge axis of symmetry (the spread angle) is presented in detail. The tumbling frequency of the segments as a function of their velocity and final length is also predicted by the theory. The predictions made by applying the model to the standard 83.8 mm 42 degrees opening angle B.R.L. precision shaped charge were found to be consistent with the data published in open literature. The comparison of these predictions with the data leads also to the conclusion that the cutoff in the copper jet penetration into steel targets occurs when the jet segments start to hit the walls of the already formed hole instead of reaching its bottom without being disturbed on their way.  相似文献   
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A series of water‐soluble and water‐insoluble heteroxylans, citrus pectin, and both starch components, amylose and amylopectin, were hydrophobically modified by introducing low amounts of p‐carboxybenzyl groups at constant reaction conditions. The achieved degree of substitution ranged from 0.03 to 0.22. The derivatives were characterized by chemical and spectral analyses. They exhibited tensioactive properties evaluated by various surface‐activity tests. The results indicate a weak surface tension‐lowering effect and low foamability of all derivatives. However, significant emulsifying and protein foam‐stabilizing effects were found for most of the studied derivatives, the most pronounced for the modified pectin and acidic xylans. The rheological behavior of the derivatives was investigated by rotational and oscillation rheometry. The results indicated that the hydrophobic interactions lowered significantly the apparent viscosity of the xylan dispersions and introduced changes, particularly in their flow properties. © 2000 John Wiley & Sons, Inc. J Appl Polym Sci 78: 1191–1199, 2000  相似文献   
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Micro- and macro-cellular SiCN and SiOCN foams were produced via two different routes by using a polysilazane preceramic polymer. In the first route, a mixture of partially cross-linked polysilazane and poly(methylmetacrylate) microspheres, used as sacrificial fillers, was warm pressed and subsequently pyrolyzed to create micro-cellular foams. In the second route, liquid polysilazane was mixed with a physical blowing agent and the blend was cured and pyrolyzed, leading to the formation of macro-cellular ceramics in a one-step process. Ceramic components of different morphology and characteristics, depending on the processing method adopted, were fabricated. The foams had a mostly interconnected porosity ranging from 60 to 80 vol% and possessing a compressive strength in the range 1–11 MPa. Some oxygen contamination was found in the foams obtained using the sacrificial fillers, probably because of the adsorbed humidity on their surface. The polymer derived ceramic (PDC) route is an efficient and cost effective way to produce SiCN-based foams possessing tailored pore architecture and properties suitable for high temperature applications.  相似文献   
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The mobile computing environment provides many benefits such as ubiquitous access to computing but includes constraints on resources such as available bandwidth and battery life. Replication is a widely recognized method for balancing the demands of storage space with bandwidth and battery life. We propose a novel scheme that seeks to strategically balance these constrained resources through a cooperative game-theory approach for replication in a mobile environment. Our replication strategy relies on the cooperation of the nodes within the network to make replica caching decisions which are spatiotemporally local-optimal for the network from an energy and bandwidth conservation standpoint. In cooperative altruistic data replication, each node calculates the net global benefit, for caching a replica of the requested data, as the result data is returned from the responding node to the requesting node, where it determines the spatiotemporally local-optimal node for replicating the data item. Performance results from our research indicate that our scheme, CADR, improves the query response time by 25 and 45 %, mean hop count is improved by 26 and 46 %, query error is reduced by 30 and 48 %, while energy utilization is reduced 30 and 57 % when compared with both another game theoretic replication approach and standard cooperative caching respectively.  相似文献   
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The study reports on block shear investigations with bondlines of face-glued laminations and matched solid wood specimens from hardwood glulam (GLT) beams produced industrially from eight technically and stand volume-wise important species. The European hardwoods comprised oak, beech, sweet chestnut and ash and the tropical species were teak, keruing, melangangai and light red meranti. The adhesives were phenol-resorcinol and melamine-urea. When combining all species in one sample, a rather strong linear relationship of bond and wood shear strength was observed. The ratio of bond vs. wood shear strength was for all species on the mean value level?≥?0.9, and likewise (with one exception) for the respective strengths’ 5%-quantiles. Consistent with literature, the test results showed no significant correlations between bond shear strength and density, wood shear strength and wood failure percentage of individual species, respectively. The investigations render the methodological basics of some international standards on bond quality verification as being inappropriate. New, empirically validated hardwood GLT bond requirements are proposed for discussion and implementation at the CEN and ISO levels. The strength ratio specifications reflect respective ANSI provisions, yet the reference quantity wood shear strength is now determined in an unbiased manner from matched GLT specimens. The wood failure verification proposal is based on the 10%-quantile and mean level for initial type testing and factory production control. The requirements further account for the pronounced difference observed in scatter of wood failure between European and tropical species.  相似文献   
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The increasing incidence of trauma in medicine brings with it new demands on the materials used for the surgical treatment of bone fractures. Titanium, its alloys, and steel are used worldwide in the treatment of skeletal injuries. These metallic materials, although inert, are often removed after the injured bone has healed. The second-stage procedure—the removal of the plates and screws—can overwhelm patients and overload healthcare systems. The development of suitable absorbable metallic materials would help us to overcome these issues. In this experimental study, we analyzed an extruded Zn-0.8Mg-0.2Sr (wt.%) alloy on a rabbit model. From this alloy we developed screws which were implanted into the rabbit tibia. After 120, 240, and 360 days, we tested the toxicity at the site of implantation and also within the vital organs: the liver, kidneys, and brain. The results were compared with a control group, implanted with a Ti-based screw and sacrificed after 360 days. The samples were analyzed using X-ray, micro-CT, and a scanning electron microscope. Chemical analysis revealed only small concentrations of zinc, strontium, and magnesium in the liver, kidneys, and brain. Histologically, the alloy was verified to possess very good biocompatibility after 360 days, without any signs of toxicity at the site of implantation. We did not observe raised levels of Sr, Zn, or Mg in any of the vital organs when compared with the Ti group at 360 days. The material was found to slowly degrade in vivo, forming solid corrosion products on its surface.  相似文献   
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