In this article, an alternative for Tinto's integration theory of student persistence is proposed and tested. In the proposed theory, time available for individual study is considered a major determinant of both study duration and graduation rate of students in a particular curriculum. In this view, other activities in the curriculum, in particular lectures, constrain self-study time and therefore must have a negative impact on persistence. To test this theory, we collected study duration and graduation rate information of all-almost 14,000 students-enrolling in eight Dutch medical schools between 1989 and 1998. In addition, information was gathered regarding the timetables of each of these curricula in the particular period: lectures hours, hours spent in small-group tutorials, practicals, and time available for self-study. Structural equation modeling was used to study relations among these variables. In line with our predictions, time available for self-study was the only determinant of graduation rate and study duration. Lectures were negatively related to self-study time, negatively related to graduation rate, and positively related to study duration. The results suggest that extensive lecturing may be detrimental in higher education. However, in the curricula employing limited lecturing considerable energy was spent in supporting self-study activities of students and preventing postponement of learning. Given our findings, both activities will likely have large pay offs, in particular in curricula with low graduation rates.

The transition from undergraduate medical education to learning in clinical clerkships can be difficult for students. Learning in clinical practice requires awareness of learning opportunities and goals, active elaboration and reflection. Staff should provide students with guidance to learn from their experiences. A new Introductory Clerkship was designed to facilitate the start of goal-oriented, active and reflective work-based learning. This four-week clerkship is a result of the cooperation of six major specialties in the university hospital. The innovations included explicitly formulated goals, a description of the student's activities in daily practice and of the staff's role, group meetings, a logbook, a halfway formative interview and a final summative interview. The aim of this study was to investigate to what extent the innovations of the new Introductory Clerkship were implemented and how students and residents valued them. Two questionnaires were constructed: one was administered to students (n = 54) and the other to residents (n = 27). Students considered participation in daily practice very instructive, although more observations of history taking and physical examination are wanted. The interviews and group meetings promote students' learning. Use of the logbook needs improvement. Residents perceived a shortage of time and would appreciate more participation of staff members, as well as a better preparation for supervising tasks. Overall, the study demonstrates that it is possible to introduce innovations in clinical clerkships to improve the learning environment of work-based learning.

Using oligonucleotide primers complementary to the unique immunoglobulin heavy chain CDRIII sequence of the malignant clone, we developed tumour-specillc PCRs capable of detecting one tumour cell in a background of 104

The case histories of 252 adolescent and adult patients with acute leukemia diagnosed and treated between 1975 and 1985 are analyzed with special attention to prognostic factors determining the second complete remission (CR) rate. A first CR was achieved in 65% of cases, 60% for acute myelogenous leukemia (AML), and 75% for lymphoblastic leukemia (ALL). In 86 patients a relapse occurred (50 AML, 36 ALL), and 50% of them entered a second CR after reinduction therapy. Median survival after first relapse of these reinduction-responders was significantly prolonged in comparison to the reinduction-nonresponders for both AML (15 versus 2 months) and ALL (11 versus 3 months). Median duration of the first CR of the reinduction-responders was significantly longer than that of the second CR (13 versus 6 months). The major determinant for the probability to obtain a second CR after reinduction therapy was the duration of the first CR. The latter was significantly longer in the reinduction-responders than in the nonresponding group (13 versus 5 months). Furthermore patients younger than 40 years, and those who relapsed after ending the maintenance therapy, tended to have better chances to achieve a second CR. Rapid achievement of the first CR, and sex of the patients seemed not to be of predictive value. The authors conclude that aiming for a second CR is worthwhile in young patients who relapse after a long first CR.

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