CONTACT: Les Beitsch
(850) 645-1830
les.beitsch@med.fsu.edu

By Ron Hartung
October 2009

TALLAHASSEE, Fla. -- The Florida State University College of Medicine is using its statewide network of clinical faculty to study better ways to equip primary-care physicians to help patients stop smoking.

Andrée Aubrey, MSW, LCSW

Leslie M Beitsch M.D., J.D

The 12-month project is being conducted by Andrée Aubrey, director of the Area Health Education Center located at the college, and Les Beitsch, M.D., the college’s associate dean for health affairs, through a contract with the Florida Department of Health.

“This is an important project for the health of all Floridians,” said Mike Muszynski, M.D., the college’s regional campus dean for clinical research. “It is also the first study of its kind to test the effectiveness of a novel educational approach in training community physicians on the most effective tobacco-cessation methods for their patients. Should this prove as effective as expected, it will also lay the groundwork for similar evidence-based medical care approaches utilizing the College of Medicine’s statewide Clinical Research Network.”

The College of Medicine has campuses in six cities: Daytona Beach, Fort Pierce, Orlando, Pensacola, Sarasota and Tallahassee. Physicians who practice in each of those cities teach the FSU medical students. Out of those 1,500 physicians, researchers aim to get about 75 who are in family medicine, general internal medicine or geriatric medicine to participate in this project. Project researchers have sent a brief survey to the targeted clinical faculty.

“Physicians want to help their patients quit smoking,” Aubrey said. “They just need help in knowing how.”

In “Treating Tobacco Use and Dependence,” the U.S. Department of Health and Human Services notes that physicians are in a great position to help: Most smokers see a physician or other health professional every year; most want to quit; and most pay attention to what physicians say. “Unfortunately,” the department guidelines note, “clinicians and health systems do not capitalize on this opportunity consistently.”

This project is designed to determine the effectiveness of an approach called academic detailing. Instead of attending an educational seminar, Aubrey explained, the physicians will receive onsite training from certified tobacco-cessation specialists. Everything will be tailored to that individual practice.

The ultimate goal is to have fewer people smoking. Each year in the U.S., tobacco use accounts for more than 435,000 deaths.

CONTACT: Ron Hartung
(850) 645-9205; ronald.hartung@med.fsu.edu

By Ron Hartung
October 2009

TALLAHASSEE, Fla. -- A Florida State University College of Medicine researcher has been awarded two separate grants from the National Institutes of Health (NIH) totaling $2.4 million to continue her work in detecting autism in children as young as 18 months.

Amy Wetherby is director of the Autism Institute in the College of Medicine. For a decade her FIRST WORDS® Project has screened children to identify early red flags of various autism spectrum disorders (ASD). Among those red flags are a child’s reluctance to look at the face or eyes of others; a delay in the use of gestures, sounds and words; a tendency not to share excitement or interests; and a fixation on certain objects.

The younger the child, the more subtle the red flags but the greater the chances of working with the family to lessen the negative effects. People with autism can have many strengths, Wetherby said, citing Albert Einstein as a prime example. For some people, however, autism is a severe disability.

“The symptoms themselves can actually impair learning,” Wetherby said. “Just like cancer, the earlier we can catch it, the far better the outcomes.”

In the United States, she said, most children who have autism are usually not identified until somewhere between ages 3 and 5. The American Academy of Pediatrics recommends screening children between ages 18 and 24 months. The problem, Wetherby said, is that there is no well-validated, ASD-specific screener for that age group for use in pediatric settings.

A $1.9 million, two-year grant from the NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development will fund research that aims to develop such a screener. Wetherby’s collaborators are Eva Petkova at the New York University Child Study Center and Catherine Lord at the University of Michigan Autism and Communication Disorders Center.

A total of 600 children will participate. The researchers will study several different screening and evaluation measures that they developed. Some are designed to help parents detect red flags of ASD. Other are designed to help pediatricians and other professionals.

“By improving and streamlining early screening and diagnosis of ASD in 18- to 24-month-old children, the findings of this study will have important implications for earlier access to intervention,” the grant proposal stated.

Sometimes a screening tool that works well in one culture does not work as well in another. Wetherby’s two-year grant from the National Institute on Deafness and Other Communication Disorders, which totals more than $465,000, will fund research that may lead to culturally sensitive screening and evaluation methods.

Children of African-American and Latino families in the United States, she said, are usually not diagnosed with autism until they’re 4 to 6 years old, a full year later than other children.

“We’re trying to address that disparity by studying cultural differences in the early signs of autism,” Wetherby said.

Researchers will compare children of Latino immigrants in Immokalee, Fla., with children from the KwaZulu-Natal province of South Africa and children from Leon County, Fla. The College of Medicine has a health education site in Immokalee, and a former doctoral student of Wetherby’s, Nola Chambers, lives in South Africa. Richard Grinker, an anthropologist from George Washington University, is also a collaborator.

The American Recovery and Reinvestment Act provided the funding for the NIH grants. None of this stimulus money will be spent in Africa, Wetherby said, but in the United States it will pay for researchers and will pay families $50 for participating in assessments. Wetherby thinks it’s a good investment.

“Now we have this big chunk of money that is going to help us accelerate our findings,” she said, “which is really the idea of the stimulus money -- to use it to accelerate science.”

Both grants are funded through Aug. 31, 2011. For more information on the FIRST WORDS® Project, visit http://firstwords.fsu.edu.

CONTACT: Doug Carlson
(850) 645-1255 or (850) 694-3735
doug.carlson@med.fsu.edu

By Doug Carlson
October 2009

TALLAHASSEE, Fla. -- A Florida State University College of Medicine researcher has solved a century-old mystery about proteins that play a vital role in the transfer of the human genetic code from one cell to another. The discovery could lead to finding new ways to help the body fight a variety of diseases, including cancer.

For more than a hundred years, the best scientific evidence supported a belief that histones -- responsible for packaging DNA inside the nucleus of cells -- are highly stable proteins not rapidly degraded by the body. Yet, researchers have not previously been able to explain why free histones, if they are not degraded as other proteins are, do not accumulate in large amounts within human cells.

Akash Gunjan, an assistant professor in the department of biomedical sciences, has found evidence supporting his hypothesis that there actually are two pools of histones: one used in packaging DNA that is very stable and remains in the cell for more than a year in some cases and the other made in excess by the cells to ensure that enough histones are available for packaging the DNA. Not having enough histones results in cell death. Those excess histones, Gunjan suggests, are rapidly degraded as are other proteins.

The discovery is important because it sheds light on the way the body is able to regulate proteins for various complex tasks. Such knowledge may allow scientists to learn how to manipulate protein regulation to fight cancerous cells and thwart other disease processes. Gunjan and co-authors Rakesh Kumar Singh, Marie-Helene Miquel Kabbaj and Johanna Paik, all from the College of Medicine, published their findings in the journal Nature Cell Biology.

“This has major ramifications for all the different things the DNA does,” Gunjan said. “Because if DNA contains genes and DNA is packaged around histones, then histones are at the most fundamental level regulating whether those genes are turned on or off.”

If scientists are able to determine how genes for cancer and other diseases are turned on or off, it might lead to ways to help the body rid itself of or better control disease.

For decades scientists have been captivated by the way the body selectively uses proteins in essential functions, storing or disposing of them when they are not needed. For example, eating a hamburger requires a certain set of enzyme proteins for digestion. If the enzymes are not deactivated or degraded following digestion, the consequences would be disastrous.

“They’ll start to digest things you do not want them to digest,” Gunjan said. “After finishing your hamburger, if these enzymes started digesting proteins in your intestines, in your stomach wall and so on, that would not be a good thing.”

To manage proteins when they are not needed, the body naturally degrades them through a process known as proteolysis. Histones in most cases, however, must be preserved for long periods of time because they make it possible to fold strands of DNA measuring about 3 feet in length within the microscopic nucleus of a typical human cell. Histones used in that process must be able to avoid degradation to preserve the body’s ability to pass on its genetic code from cell to cell.

Histones, the first proteins to be purified, have been a topic of research by scientists for nearly 125 years. The mystery evolved as scientists discovered that cells have multiple copies of histone genes and make far more histones than what is needed for wrapping DNA, yet were unable to explain the apparent contradiction.

“On the one hand, you cannot find the excess histones,” Gunjan said. “On the other hand, if you propose it gets degraded, then you try to measure its rate of degradation and you find that it hangs around for several months to more than a year.”

Gunjan spent five years seeking answers to the mystery before his discovery of two separate pools of histones.

“Not only did we show for the first time that histones are unstable -- they get rapidly degraded -- we also showed this has important consequences for DNA damage and repair processes that have a major impact on cancer formation,” Gunjan said.

Additionally, previous studies published by other researchers suggest that the newly discovered regulated histone proteolysis may make significant contributions to many diverse biological processes, from the resetting of epigenetic marks on histones that help regulate gene expression, to sperm formation.

“All of this together suggests this is a very important phenomenon,” Gunjan said.

CONTACT: Doug Carlson
(850) 645-1255
doug.carlson@med.fsu.edu

Nov. 2, 2009

Dance Marathon at Florida State University and Children’s Miracle Network at Shands Children’s Hospital at the University of Florida has presented a check for $182,456.42 to the FSU College of Medicine for the benefit of children throughout Gadsden and Leon counties.

The proceeds are part of the $384,000 raised in 2009 by Dance Marathon, the largest student-run philanthropy on the FSU campus. Children’s Miracle Network at Shands Children’s Hospital at UF distributes part of the money raised to the FSU College of Medicine for use in pediatric outreach programs.

The College of Medicine is using part of the proceeds to pay for a school-based health program in Gadsden County designed to address health care disparities among area children. Other projects funded by the Dance Marathon earnings include equipment for the pediatrics unit at Tallahassee Memorial Hospital, as well as College of Medicine research projects aimed at curbing childhood obesity and its resulting Type 2 diabetes.

Participating in the signing ceremony were Dr. John P. Fogarty, dean of the FSU College of Medicine; Dr. Rick Bucciarelli, associate vice president for health affairs for government relations, professor and associate chairman of the department of pediatrics at the University of Florida; members of the FSU Dance Marathon overall committee; and FSU medical students who are part of the Pediatrics Interest Group.

CONTACT:
Brad Schmidt, (850) 644-1707; schmidt@psy.fsu.edu
or Natalie Sachs-Ericsson, (850) 644-4576; sachs@psy.fsu.edu

By Jill Elish
December 2009

TALLAHASSEE, Fla. - Every New Year, many smokers resolve to kick the habit but older smokers may have a leg up on their younger counterparts, according to Florida State University researchers who developed an intensive 16-week cessation program.

Psychology professors Natalie Sachs-Ericsson and Brad Schmidt surveyed 88 smokers participating in the cessation program and found that older smokers were more likely to cite health concerns as the reason they wanted to quit, while younger smokers were more motivated by financial reasons or the desire to prove their self-control.

“Many of the older smokers have significant health problems,” Schmidt said. “When there is the combination of a health issue and distress about that issue, we see a high motivation to quit. Young people intellectually understand the health risks of smoking, but these risks do not appear to be sufficiently salient in terms of what it takes to get them to quit.”

Consequently, it’s the older smokers — defined as those 55 and older — who are having more success in quitting. Of 37 participants — 19 of whom were over 55 and 18 younger — who had completed a follow up at least one month after the treatment, 68.4 percent of the older participants were smoke-free versus 44.4 percent of younger smokers.

“The older smokers have so much more work to do because they have been smoking longer, smoke more and are more addicted,” Sachs-Ericsson said. “They are very distressed about their health. But it is this very distress and concern for their health that plays a pivotal role in their motivation to quit.”

The findings are significant because current treatment plans do not consider different motivations for quitting across the lifespan, according to Schmidt and Sachs-Ericsson. They are now developing a proposal for a unique new treatment plan that specifically targets older smokers.

“The needs of individuals and effective tools in smoking cessation treatments may differ depending on the age of the individual,” Sachs-Ericsson said. “We believe we may have an even higher rate of smoking cessation success among older adults if we would more directly address their health concerns and the considerable benefits they will experience, even at a late age, from smoking cessation.”

Cigarette smoking is the leading cause of preventable death and disability in North America, but overcoming nicotine addiction is very difficult without a multifaceted strategy such as the one the Florida State program employs, according to Schmidt.

The researchers, in collaboration with College of Medicine Assistant Professor Mary Gerend, developed the cessation program with a $375,000, three-year grant from the James and Esther King Biomedical Research Program. It includes education, group sessions with a therapist and nicotine replacement therapy, also known as “the patch.”

Daily smokers between the ages of 18 and 65 who are in good health are eligible to participate in the program. Participants are expected to attend screening appointments, weekly group sessions and follow-up appointments. In return, they will receive free nicotine patches and can earn up to $120 for taking part in the assessments.

For more information, call the Anxiety and Behavioral Health Clinic at (850) 645-1766 or visit

www.anxietyclinic.fsu.edu/research.htm

After a national search, Richard Nowakowski, Ph.D., has accepted an offer to join the Florida State University as professor and chair of the Department of Biomedical Sciences at the College of Medicine.

Dr. Nowakowski, whose leadership of the department will begin officially in March, is currently a professor of neuroscience and cell biology at the Robert Wood Johnson Medical School in Piscataway, N.J., and the New Jersey Professor of Spinal Cord Research. He also directs the medical school’s postdoctoral career development program.

With a wealth of experience ranging from his own funded research projects and service on grant review panels to teaching and editing, Nowakowski joins the FSU College of Medicine at an opportune time.

“It is clear that the next decade will bring revolutionary changes in the structure of medical schools, the economy and also science,” he said. “These changes will be layered on top of the major scientific revolution of the past decade, specifically the sequencing of genomes that has quite literally changed the world of biology.”

Nowakowski, a graduate of the University of Wisconsin, earned a Ph.D. in cell and developmental biology from Harvard University. He completed his postgraduate education at Duke University and the Max Planck Institute for Biophysical Chemistry.

“I am very pleased that this distinguished scientist and teacher is joining our ranks,” said College of Medicine Dean Dr. John Fogarty. “He has a national reputation as a scholar and mentor and is the perfect candidate to continue to build and expand upon our initial research success. His extensive background and experience in research, medical education and academic leadership will serve the department well into our next decade.”

After joining the University of Medicine and Dentistry of New Jersey in 1985, Nowakowski spent 20 years as neuroscience course director for the Robert Wood Johnson Medical School while also teaching neuroscience and genetics. For the past five years, he also has served as director for the history of neuroscience course taught to Rutgers University graduate students.

The named chair for senior faculty funded by the New Jersey Commission on Spinal Cord Research provides support for his work on an analysis of the cell cycle and stem cell proliferation after spinal cord injury.

Nowakowski takes leadership of a department that has made significant contributions to the 500-percent increase in overall research grant funding at the FSU College of Medicine since 2002. Research in the department of biomedical sciences focuses on the molecular basis of human disease and, in addition to faculty, currently provides learning and mentoring opportunities for more than 100 undergraduate students, graduate students, and postdoctoral fellows.

His hiring concludes an exhaustive search.

“I would like to express my sincere appreciation to all the faculty and staff that participated in the search process and helped bring it to a successful conclusion,” Fogarty said. “I would especially like to thank Dr. Ken Brummel-Smith, who chaired the search committee, and all the members of his committee for their dedication and diligence in helping us recruit our newest chair.”

CONTACT: Lei Zhu
(850) 645-6813
lzhu@fsu.edu

By Barry Ray
January 2010

A team of Florida State University researchers will use a five-year, $1.3 million grant from the National Institutes of Health to develop a way to measure levels of the trace metal zinc in the human body.

Scientists have long known that zinc plays a critical role in numerous biochemical processes, but exactly how it works has never been clear, due partly to the lack of an effective means for measuring its varying levels of concentration.

Led by Lei Zhu, an assistant professor of chemistry and biochemistry, the Florida State team received the grant from the National Institute of General Medical Sciences (NIGMS), one of 27 research centers and institutes that comprise the NIH. They will work to develop a method for measuring the levels of zinc ions (Zn2+) in biological samples through an analytical process known as fluorescence microscopy.

“Zinc is essential for a wide variety of physiological functions within the human body,” Zhu said. “Just to cite a few examples, it plays a major role in cell division, the synthesis of DNA, the production of proteins and enzymes, and proper immune function. However, we still don’t have a solid understanding of the mechanisms behind these biological processes, or even of how much daily intake of zinc is required in the human diet.”

Complicating matters is the fact that Zn2+ levels aren’t uniform throughout the body. While an average adult’s body may contain from 2 to 4 grams of the mineral, most of that can be found in a few key places — the brain, kidneys, liver, bones and muscles — with the highest concentration located in the eyes and the prostate gland in men.

“The successful completion of this research project will result in a valuable new technique for measuring the distribution of Zn2+ ions in various biological systems throughout the body,” Zhu said. “This in turn could help other scientists to identify therapeutic targets for diagnosis and treatment of diseases related to the disruption of zinc homeostasis.”

Building on previous findings in Zhu’s laboratory, he and his colleagues will seek to design and prepare new, fluorescent probe molecules that will bind to Zn2+ ions over broad concentration ranges, thus allowing for far greater sensitivity and accuracy in measuring the levels of zinc found in biological samples. In particular, the researchers hope to use the probe molecules to measure zinc levels in neurons found in a part of the brain known as the hippocampus. A better understanding of zinc’s neurochemical role in the hippocampus could one day lead to more effective treatments for depression, autism, schizophrenia and other disorders.

Other Florida State researchers working with Zhu on the NIGMS project are Cathy W. Levenson, an associate professor in the Department of Biomedical Sciences within the College of Medicine; and Michael W. Davidson, a research associate at the National High Magnetic Field Laboratory and one of the world’s foremost experts in the field of optical microscopy.

Zhu, whose own research typically focuses on the areas of organic chemistry and materials science, expressed excitement about the opportunity to work with scientists from other disciplines whose knowledge complements his own.

“Cathy is an expert in neurosciences and has contributed greatly to our understanding of the effects of zinc on the function of brain neurons,” Zhu said. “And Mike is one of the best microscopists in the world. I’m happy that we can work together to tackle such a complicated scientific problem, which has elements of synthetic chemistry, bioinorganic chemistry, microscopy, cell biology and neuroscience.”

An abstract of the team’s research project, titled “Development of Sensitive Fluorescent Probes for Physiological Zn2+ Over Large Concentration Ranges,” is available at http://tr.im/L88I.

March 1, 2010

Richard Nowakowski is not only the new chair of Biomedical Sciences but also the first Randolph L. Rill Professor of Biomedical Sciences in the College of Medicine.

This is the medical school’s first named professorship. Different from “Distinguished Research Professor” and other titles, a named professorship at Florida State University generally honors a past member of a department’s faculty. It requires the provost’s approval.

Rill, a founding member of the College of Medicine’s faculty, died last year. He established the biochemistry content of the medical curriculum, played a key role in establishing the Biomedical Sciences Ph.D. program, served as its director, and wrote the successful proposal for the M.S. in Biomedical Sciences Bridge to Clinical Sciences degree for our Bridge program. The first Bridge students to earn M.S. degrees will graduate this spring.

Rill’s widow, Louise Rill, wrote in a letter to Dean John P. Fogarty that the family greatly appreciated this acknowledgment of her husband’s work.

“Randy was inspired by his students and grateful for his fine colleagues in a profession that he loved,” she wrote. “A named professorship in the Department of Biomedical Sciences is a wonderful tribute that he would find a deep honor.”

Nowakowski this week officially began his role as Biomedical Sciences chair. The eminent neuroscientist earned tenure moving up through the academic ranks at the Robert Wood Johnson Medical School of New Jersey. He has had a very successful career in research and teaching, earning the recognition of his peers in awards, grants and contracts, publications, study section memberships and more. He has held a named chair at the RWJ Medical School.

“He has earned the stature required of a named professor at Florida State University,” Dean Fogarty said.

CONTACT:
Ron Hartung, (850) 645-9205; ronald.hartung@med.fsu.edu
Marshall B. Kapp, (850) 645-9260; marshall.kapp@med.fsu.edu

By Ron Hartung
March 2010

TALLAHASSEE, Fla. - The Florida State University Center for Innovative Collaboration in Medicine & Law has been established to promote cooperation between two professions that often view each other warily.

The center, a joint effort of Florida State’s College of Medicine and College of Law, is based in the medical school. Marshall Kapp, previously the Garwin Distinguished Professor of Law and Medicine at the Southern Illinois University Schools of Law and Medicine, has been named its director.

“Its unique mission is collaboration starting at the student level, through the practitioner level, through the policy level — collaboration on behalf of the consumer, who’s the doctor’s patient and the lawyer’s client,” said Kapp, who is also a professor in the medical school’s Department of Geriatrics, a courtesy professor in the law school and an affiliate of the Claude Pepper Institute at Florida State.

“Many law schools have health-law centers; many medical schools have medical humanities departments that touch upon legal issues. But I think both in terms of its potential educational program and projects it might do, this mission is unique for an academic enterprise.”

Kapp, who has a law degree and a master’s degree in public health, also is professor emeritus from Wright State University School of Medicine and for more than 20 years was on the adjunct faculty at the University of Dayton School of Law. He is current editor of the American College of Legal Medicine’s Journal of Legal Medicine and serves on the editorial boards of several other major journals in health law. He has published and spoken extensively on topics in health law, medical ethics, and law and aging.

Kapp said the idea for the center arose from informal conversations among faculty members at the medical and law schools.

“One of the premises of the new center is that, yes, there’s a certain innate distrust, and we’re not going to make everybody love each other, but we’re going to try to break down the barriers enough to at least identify the areas where we can work together,” Kapp said.

Among the center’s constituents, he said, will be policymakers, both public (such as legislators) and private (such as insurance companies).

“As an academic institution, we can present information and counsel without having our own agenda, other than wanting to benefit consumers — patients and clients,” he said. “I think if we can establish that credibility, legislators will come to us. Whether we do briefings, programs or publications for the policymakers, they will see what we have to say on issues.”

Among the many issues the center will address, he said, is end-of-life care.

“That issue is a good example of a situation where doctors’ anxieties and apprehensions about the law and their own legal exposure influence how they treat patients,” Kapp said. “So through this center, I want to identify those kinds of issues and ask: What are their apprehensions? Where do doctors get these legal fears? Are they justifiably worried, or is it a matter of misunderstanding and missing information? If that’s the case, then one remedy is education. And to the extent that doctors are justifiably fearful, to the extent that the law actually does work at cross purposes with ethics and medicine, what can we recommend to policymakers to change the law?”

Perhaps the best-known fault line between medicine and law, Kapp noted, is the debate over medical malpractice.

“The two primary objectives of the current system are to compensate people who are, through no fault of their own, injured while receiving medical care, and to improve medical care, to deter bad practice,” he said. “The question is: What’s the best way to achieve those two objectives? Is it the current tort system, or is it some other system? You can’t really talk a lot about collaboration between the two professions and ignore the liability concerns.”

But the field of medicine and law is much broader than just the liability question, he said, and there is much for this new center to explore.

John Fogarty, dean of the College of Medicine, is enthusiastic about the possibilities.

“This new center provides Florida State University an incredible opportunity to truly build collaborative programs between our medical school and law school that should set the national model,” Fogarty said. “Sharing faculty and resources and providing expertise and frameworks for looking at the difficult ethical, moral and health care-related concerns of our society should be a great benefit to our university and our state.”

Donald Weidner, dean of the College of Law, is equally optimistic.

“We hope to help bridge the gap between the professions of law and medicine,” he said, “to improve the health and justice systems for all our citizens.”

March 3, 2010

The College of Medicine and four other colleges at The Florida State University joined together March 2 to host “Healing and the Arts: Space Between Breaths,” an event that explored ways in which loss and grief can serve as a motivational force in people’s lives.

The centerpiece of the event was a 2 p.m. screening of the film “Space Between Breaths.” Featuring conversations with parents who have experienced the death of a child, including parents who lost children at Columbine, on Sept. 11 and in the Iraq war, the documentary offered a healing perspective on loss.

Two-time Grammy-nominated recording artist Cindy Bullens, who contributed the musical score for the film, performed live following the film presentation. The event concluded with a panel discussion that included Bullens; Luther and Rosemary Smith, producers of “Space Between Breaths”; Nick Mazza, interim dean of the College of Social Work; Sally Karioth, professor of nursing; Mindi Rojas, an art therapist at Big Bend Hospice; Dr. Harold Bland, a pediatrician and interim chair of the Department of Clinical Sciences at the College of Medicine; and Darcy Walworth, assistant professor of music therapy.

“This allows us to share with our community an event that highlights the resilience of families that have had significant losses in their lives,” said Pam Graham, associate professor of the College of Social Work, who coordinated the event.

It was sponsored by the colleges of Medicine, Music, Nursing, Social Work and Visual Arts, Theatre and Dance. Physicians were able to earn Continuing Medical Education credits for attending.