Medicine and Health Sciences Commons^™

Implementation Of The Modified Severity Assessment Scale (Msas) For Alcohol Withdrawal In An Inpatient Psychiatric Unit, Grace R. Lindsey

Doctor of Nursing Practice

Background: Alcohol withdrawal is a potentially life-threatening condition frequently seen in psychiatric inpatient settings, especially among individuals with co-occurring alcohol use disorder and mental illness. The Clinical Institute Withdrawal Assessment for Alcohol Scale-revised, while widely used, depends on patient self-report, making it less effective for individuals with altered mental status or psychosis.

Purpose: This quality improvement project implemented the Modified Severity Assessment Scale, an objective, observation-based alcohol withdrawal protocol, in an inpatient psychiatric setting to improve safety, treatment accuracy, and care standardization.

Objectives: The project focused on ensuring full staff adoption of the protocol, reducing intensive care unit transfers …

Enhancing Adherence To Veterans Affairs/Department Of Defense And American Psychiatric Association Clinical Guidelines For Alcohol Use Disorder, Corinna M. Trevino

Doctor of Nursing Practice

Alcohol use disorder continues to be significantly undertreated within outpatient behavioral health settings, particularly concerning pharmacological interventions. Despite the presence of robust national clinical guidelines recommending medications such as naltrexone for individuals with moderate to severe dependence, the rates of prescribing these medications remain modest owing to inconsistent screening procedures, limited referral practices, and provider follow-through barriers. This project was implemented at a substance use treatment center in a large metropolitan area to improve adherence to clinical practice guidelines. The purpose of this project was to increase prescribing of naltrexone and improve referral for patients with moderate to severe alcohol …

Examining And Addressing Increased Hospital Inpatient Falls Rates At An Urban Community Hospital, Juan Lira

Doctor of Nursing Practice

Abstract

Background: Falls are the leading cause of reported injuries within the hospital setting. Injuries from falls occur in about20-45% of the time and is the leading cause of injury and injury death among the adult population. Inpatient falls are associated with an additional $14,0000 per occurrence and a prolonged hospitalization by 6.3 days. Increased falls rates affect hospitals rating, accreditation and reimbursements. This hospital is experiencing inpatient falls that exceed national average and corporate goals.

Purpose: The purpose of this project is to reduce the hospital falls rate by 10% within 90 days of initiating evidence-based evaluation and facility-wide …

Implementation Of An Information Sheet For Pediatric Patients With Autism Spectrum Disorder In An Inpatient Setting To De-Escalate Aggressive Behaviors And Reduce Seclusion Rates, Megan R. Castro

Doctor of Nursing Practice

Introduction: Research shows that most seclusion events in pediatric psychiatric settings involve pediatric patients with neurodevelopmental disorders, particularly autism spectrum disorder (ASD). A lack of provider expertise contributes to elevated seclusion rates, highlighting the need for evidence-based, ASD-informed care.
Purpose: To reduce seclusion events within a pediatric psychiatric facility in South Texas, by implementing an evidence-based intervention upon admission that could decrease aggressive behaviors and the likelihood of requiring seclusion. Evidence summary: Literature and guidelines underscore the importance of identifying sensory triggers and calming strategies at admission. Collaborative care and personalized interventions, such as a patient information sheet that identifies …

Implementing A Cardiac Catheterization Pre-Procedure Protocol To Decrease Avoidable Same-Day Cancellations, Christina C. Perry

Doctor of Nursing Practice

Background and significance of the problem: Pediatric congenital heart defect patients are amongst the sickest hospital population. These patients require planned palliation in the cardiac catheterization lab (cath lab), which has a limited number of providers and appointments available. In the cath lab, the percentage of avoidable same-day cancellations for interventional procedures was found to be greater than 30%, representing significant resource utilization opportunities.

Purpose: The purpose of this project was to develop and implement a standardized, evidence-based pre-procedure protocol to decrease avoidable same-day cath lab cancellations.

Goals and objectives: The goals of this project were a 10% decrease in …

Power, Interests, And Maternal Health Care: A Political Economy Analysis Of Service Delivery Redesign In Kenya, Jacinta Nzinga, Easter Olwanda, Kennedy Opondo, Hillary Kimutai, Jan Cooper, Brian Arwah, Benjamin Tsofa, Edwine Barasa, Kevin Croke

Institute for Human Development, East Africa

The maternal and newborn health (MNH) service delivery redesign (SDR) in Kakamega County, Kenya, represents the country's first system-level reorganization of MNH services. The reform aimed to improve care quality and reduce mortality by centralizing delivery services at designated hubs. Using a political economy lens, we examined how ideology, political dynamics, and institutional structures shaped the agenda-setting, adoption, implementation, and sustainability of SDR. We drew on data from document reviews, stakeholder analysis, semi-structured interviews, and non-participant observation to assess the structural, contextual, and institutional factors influencing the reform. Ambiguity around SDR's purpose contributed to the community's uncertain engagement characterized by …

John Henryism And The African American Experience: An Exploration Of Risk And Protective Factors And Health Outcomes, Joseph L. Twitdy

All-Inclusive List of Electronic Theses and Dissertations

Racial discrimination has been tied to adverse mental and physical health outcomes among African Americans. In the face of this adversity, African Americans have developed strategies for coping with everyday experiences of discrimination. One such coping method is based on the concept of John Henryism. The folktale of John Henry tells the story of an African American steel-driver racing against a steam-powered drill to clear a path for trains through a mountain. Although John Henry wins the race, he later dies due to exhaustion, ultimately passing with his hammer in his hand. The psychological concept of John Henryism (JH) refers …

Quality Of Life And Mental Health: A Qualitative Exploration Of Perceived Factors That Impact Older Adults, Chasiti Herring

All-Inclusive List of Electronic Theses and Dissertations

Enhancing quality of life and well-being is a universal phenomenon across the lifespan. As the population ages, older adults are in great need of supportive services to enhance quality of life and their ability to manage their mental health. The purpose of this study is to examine the quality of life (QoL) of older adults. This study aimed to provide valuable research in the area of QoL through the exploration of perceived factors that impact the older adult population. This exploratory qualitative research study consisted of 10 older adult participants between the ages of 65 and 95. Research recruitment prioritized …

Implementing Pain Curricula In Prelicensure Physical Therapy Education: Faculty Perspectives And Experiences, John D. Kiesel

All-Inclusive List of Electronic Theses and Dissertations

The impact of pain on society has implications for individuals’ well-being and the overall health of society. Despite the high prevalence of pain, many new healthcare providers often lack the confidence and skills to manage patients with pain effectively. This phenomenological research study aimed to understand the lived experiences of faculty responsible for developing and delivering pain education to prelicensure physical therapy students. A secondary purpose was to examine the barriers that exist from the perspective of faculty members with subject matter expertise in pain education to implementing effective pain education in prelicensure curricula. Prelicensure pain education is essential for …

Assessing U.S. Fatal & Nonfatal Injury Trends By Worker Age, Alexander Mcdaniel

All-Inclusive List of Electronic Theses and Dissertations

Occupational injuries and fatalities in the United States have declined over time; however, meaningful differences by worker age remain a concern for employers and safety professionals. Younger workers often experience higher non-fatal injury rates due to limited experience and developing hazard-recognition skills, while older workers face increased risk of severe and fatal outcomes related to age-associated physical changes. The purpose of this study was to analyze long-term injury and fatality trends by age group and determine whether differences exist over time. National injury data from the Census of Fatal Occupational Injuries (1992–2023) and the Survey of Occupational Injuries and Illnesses …

Athletic Participation Among Students And Its Correlation To Increased Outcomes In Academic Performance, Benjamin Carl Anderson

All-Inclusive List of Electronic Theses and Dissertations

This quantitative study investigated the correlation between student participation in athletic-based extracurricular activities and academic performance among high school students in rural Indiana. The research sought to determine whether athletic involvement contributes to academic success indicators such as PSAT and SAT scores, and school attendance. The study looked at how athletics can serve as a lever for improving academic outcomes and supporting students in meeting the criteria for postsecondary readiness. Key research questions explored the influence of gender, ethnicity, grade level, and attendance on academic performance within the subset of students participating in athletics. A review of the literature supported …

Infographic | Focus On American Indian Students In North Dakota: Advancing Oral Health Equity Through School-Based Prevention, Rashid Ahmad, Shawnda Schroeder

Indigenous Health Faculty Publications

SEAL!ND brings dental screenings, fluoride varnish, dental sealants, education, and referrals directly into schools, removing transportation and cost barriers that often limit access to care. In 2024–25, 21% of students served were American Indian, compared with 5.7% of North Dakota’s population. Across four years of data, American Indian students show measurable progress in oral health, even as inequities remain.

From Standard To Stratified: Modeling Ntcp And Ear To Personalize Daily Mv-Cbct In Radiotherapy., Duong Thanh Tai, Luong Tien Phat, Tran Trung Kien, Duong Tuan Linh, Nguyen Ngoc Anh, Nguyen Quang Hung, Peter Sandwall, Parham Alaei, David Bradley, James C L Chow

Oncology Articles

PURPOSE: To evaluate the cumulative radiobiological impact of daily megavoltage cone-beam computed tomography (MV-CBCT) imaging dose based on normal tissue complication probability (NTCP) and excess absolute risk (EAR) of secondary malignancies among radiotherapy patients treated for breast, pelvic, and head & neck cancers. This study investigated whether MV-CBCT imaging dose warrants protocol personalization according to patient age, anatomical treatment site, and organ-specific radiosensitivity.

METHODS: This retrospective study included cohorts of breast (n = 30), pelvic (n = 17), and head & neck (n = 20) cancer patients undergoing radiotherapy with daily MV-CBCT. Imaging dose distributions employing two common MV-CBCT protocols …

Evaluating Perceptions Of Clinical Sports Pharmacists: Insights From An Orthopedic Clinic Survey, Brandon K. Welch, Sara Panella, Michael Swartzon, Eli Friedman, Samantha Cossin

Nursing & Health Sciences Research Journal

Introduction: Athletes have unique pharmaceutical needs due to injury risk, supplement use, and anti-doping regulations. Despite this, pharmacists remain underutilized in sports medicine. This quality improvement project evaluated clinician and staff perceptions of clinical sports pharmacists at Baptist Health, a large healthcare system in South Florida.

Methods: A 12-question REDCap survey was distributed to 19 staff and clinicians— including physicians, athletic trainers, and medical assistants—across five Baptist Health Orthopedic and Sports Medicine clinics. Responses were measured using a Likert scale and analyzed using descriptive statistics and thematic analysis.

Results: The survey achieved a 100% response rate. Most participants had over …

Post-Discharge Transitions Of Care Pharmacists Follow-Up Impact On Patient Care, Lesly Rapado, Sara Panella, Elaina Rosario, Emilie Collongette, Faaria Quadri, Beatriz Jimenez-Cadilla, Amanda Gronniger

Nursing & Health Sciences Research Journal

Introduction: This quality improvement project assessed the impact of a newly implemented transitions of care (TOC) pharmacist service at a large health system. The service involves a comprehensive review of recently discharged value-based care individuals, including chart review and, when necessary, telephonic follow-up by the pharmacist 3-6 days post-discharge.

Methods: This retrospective evaluation compared two groups: pre-implementation (September 1st, 2023 - January 30th, 2024) and post- implementation (March 1st, 2024 - July 30th, 2024) of TOC pharmacist service, focused on patient evaluations 3-6 days post-discharge. The primary outcome was a composite of 30-day re-hospitalization rates including urgent care, emergency department, …

An Objective Structured Clinical Examination (Osce) For Spinal Anesthesia Utilizing Landmarks And Ultrasound Guidance, Ashley Craven, Marli Gray

Doctoral Projects

Spinal anesthesia, a critical regional anesthetic technique, is frequently administered by Certified Registered Nurse Anesthetists (CRNAs) for a variety of surgical procedures, especially those involving areas below the umbilicus. However, CRNAs' experience with spinal blocks may vary when transitioning to new hospital environments, necessitating continued education and skill assessment. This doctoral project aims to address the knowledge gaps through the development of an Objective Structured Clinical Examination (OSCE) specifically designed for CRNAs.

The OSCE incorporates current best practices and research on spinal anesthesia, offering CRNAs an instructional framework for administering spinal blocks using both traditional landmark techniques and ultrasound guidance. …

An Objective Structured Clinical Examination (Osce) For Axillary Nerve Blocks Using Ultrasound-Guidance And Landmark Techniques, Bailee Ladner, Hannah Wallace

Doctoral Projects

The purpose of this doctoral project was to create an informative educational and evaluation tool on axillary brachial plexus nerve blocks using ultrasound-guided and landmark techniques for Certified Registered Nurse Anesthetists (CRNAs). CRNAs can use this in the clinical setting to help improve understanding and performance of axillary brachial plexus blocks. Axillary brachial plexus blocks are beneficial in providing analgesia throughout the perioperative period while minimizing risks associated with general anesthesia. Additionally, axillary blocks have a more desirable safety profile than other peripheral nerve blocks, such as supraclavicular nerve blocks. Local anesthetic systemic toxicity (LAST), due to accidental vascular puncture, …

Diabetes And Hypertension Frequencies And Trends In The Health Districts Of Sololá, Alejandro Cerón, Sophie Perfetto, Ana Textor, Sidona Alemayehu, Emilia Alvear Escobar, Adele Beard, Sarah Berson, Rachel Bryant, Jennifer Calzontzi, Rylee Castro, Eva Cress Palencia, Jake Czarnecki, Jordyn Epstein, Nikki Harris, Patience Hinojos, Max Hippisley, Erin House, Jackson Hullett, Nathan Johnson, Amelie King, Saule Lankelyte, Juan Loya, Ashley Mackenzie, Ilana Mighdoll, Molly Morrill, Maria De Jesus Ramos Jimenez, Lilly Teklemedhin, Joseph Trujillo, Lauren Verachtert, Nathan Verachtert, Violet Vreeland, Alex Welch, Jada Wright

Anthropology: Undergraduate Student Scholarship

This report was prepared by the students, Graduate Teaching Assistants, and instructor of “The Social Determination of Health” class taught in the fall of 2025 at the University of Denver. The report was prepared for Dr. Luis Pablo Méndez, of the Vice Ministry of Health Regulation, Surveillance and Control, of the Ministry of Public Health and Social Assistance of Guatemala. The work used the following guiding question: How can available data about service production can be used to inform the planning process for the implementation of the Global Hearts Initiative’s HEARTS technical package in the Distrito de Redes Integradas de …

Across The Pond, Across The Waistline: A Comparative Look At The Childhood Obesity Crisis In The United States And United Kingdom, Samantha N. Eales

Honors College Theses

Childhood obesity is no longer just a local concern; it’s a global epidemic shaping the health of future generations. This paper compares how two similar nations with drastically different healthcare systems, the United States and the United Kingdom, tackle this growing crisis. Although both countries struggle with fast food culture, sedentary lifestyles, and targeted marketing, their health policy strategies differ dramatically. The U.S. leans on community programs and education, while the U.K. enforces stronger national regulations and advertising restrictions. By examining nutrition, physical activity, and policy, this thesis explores what each country does well and where they fall short. It …

A Novel Maturation Equation For Hepatic Clearance Across Preterm, Term Neonates, Children, And Adults: Application To Paracetamol And Its Metabolite, Yunjiao Wu, Swantje Völler, Sebastiaan C. Goulooze, Karel Allegaert, Catherine M.T. Sherwin, Anne Van Rongen, Daniëlla W. E. Roofthooft, Sinno H.P. Simons, Dick Tibboel, Robert B. Flint, John N. Van Den Anker, Catherijne A.J. Knibbe

Pediatrics Faculty Publications

A preterm and term neonate to adult (PTNA) maturation equation was introduced recently to describe the glomerular filtration rate maturation from birth to adulthood for neonates of varying gestational age. This study aims to evaluate the newly developed PTNA equation against common maturation approaches like allometric scaling (AS0.75), the AS0.75 plus postmenstrual age (PMA)-based Emax (AS0.75 + PMA) equation, and the bodyweight dependent exponent equation (BDE) for the maturation of three hepatic pathways of paracetamol (PCM) from preterm and term neonates up to adults. A population pharmacokinetic analysis was conducted with pooled plasma and urine data of PCM, PCM-glucuronide (PCM-GLU), …

Issue 16: Pulmonary & Critical Care Insider, Bharat Bajantri Md, Sarah Ellsworth Mls

Critical Care & Pulmonary

Pulmonary & Critical Care Insider Issue 16

Compiled by Bharat Bajantri, MD, and librarian Sarah Ellsworth, MLS for the clinicians of the Pulmonary and Critical Care team of Parkview.

The Pulmonary & Critical Care Insider newsletter was created by Dr. Bharat Bajantri, MD and Sarah Ellsworth, MLS in 2023 as a form of current awareness for current practice at our hospital, Parkview Health.

Topics:

EVERDAC Trial: Do All Shock Patients Need Arterial Lines?

Beyond MAP: Redefining Perfusion Pressure in Septic Shock

ECG Findings You Cannot Miss in Acute Pulmonary Embolism

Food for Thought: When Private Equity Buys Hospitals, Who Pays …

Assessing Neurocognitive Functioning Among Adults Ageing With And Without Hiv At The Kenyan Coast: Measurement Issues And Correlates, Patrick Nzivo Mwangala, Carophine Nasambu, Ryan Wagner, Mihaela Duta, Gaia Scerif, Charles Newton, Amina Abubakar

Institute for Human Development, East Africa

Background: Cognitive impairment is one of the most prevalent complications of HIV infection, with significant medical and functional impacts. However, valid, and reliable assessment tools are lacking for the newly emergent ageing population of people living with HIV (PLWH) in many parts of sub-Saharan Africa (SSA), including Kenya. Without these tools, critical intervention opportunities, e.g., psychoeducation, treatment and additional support, are missed. To bridge this gap in Kenya, we adapted the Oxford Cognitive Screen Plus (OCSPlus), a tablet-based cognitive assessment tool designed for low-literacy settings, with adults ageing with HIV ≥ 50 years and their uninfected peers. This study examines …

Well-Being And Quality Of Life Of Kenyan Nurses, Midwives And Community Health Volunteers: Measurement Properties And Correlates Of The Bbq And Who-5, Paul Mwangi, Sabina Odero, Rachel Odhiambo, Brenda Nzioka, Constance Shumba, Eunice Ndirangu, Amina Abubakar

Institute for Human Development, East Africa

Healthcare workers’ quality of life (QoL) and well-being is directly linked to the quality of services they deliver. However, there is a shortage of validated measures to assess QoL, well-being and their predictors among healthcare workers in Kenya, as in other LMICs. This study aimed to assess the reliability and validity of the Brunnsviken Brief Quality of Life Scale (BBQ) and WHO-5 well-being index (WHO-5) among nurses, midwives and community health volunteers (CHVs) in Kenya. The BBQ and WHO-5 were selected due to their established psychometric strengths, brevity, and prior use in healthcare settings. Additionally, the sociodemographic, psychological, and health …

Evaluating The Impact Of Evidence-Based Guidelines On Corticosteroid Prescribing For Acute Upper Respiratory Infections In Outpatient Primary Care, Cody Allen Boyd Hyatt

Doctoral Projects

Inappropriate corticosteroid prescribing for acute upper respiratory tract infections (AURTIs) remains a prevalent issue in outpatient primary care despite limited evidence supporting their use in otherwise healthy adults. This Doctor of Nursing Practice (DNP) project aimed to reduce inappropriate corticosteroid prescribing for AURTIs by implementing an evidence-based clinical practice guideline over an eight-week period in a rural primary care setting.

The doctoral project employed pre- and post-intervention design. Providers were introduced to the corticosteroid guideline derived from the 5-Minute Clinical Consult, emphasizing appropriate use criteria for corticosteroids in AURTI cases (Unbound Medicine Inc., 2025). Educational outreach and clinical reminders …

Teaching Methods That Promote Medical Student Attendance: A Scoping Review, Jenny Mills, Sarah Keil, Pat W. Whitworth, Jamie Wiesmueller, Jeff L. Jackson

Library Faculty Scholarship

Background 

Medical student class attendance, especially traditional lectures, is on the decline. As faculty explore a variety of pedagogical approaches, understanding how to encourage attendance and engagement is critical. The purpose of this scoping review is to explore the literature to better understand the teaching methods that promote attendance.

Methods 

This scoping review was conducted as advised in the Joanna Briggs Institute (JBI) Manual for Evidence Synthesis. Five databases were systematically searched for primary studies on teaching methods that motivated undergraduate medical students to attend or not attend in-person or online synchronous class sessions. A total of 1,313 articles were …

Maternal-Infant Mortality In West Michigan: A Comparative Literature Review, Mia Cichowlas, Riley Bourlier

Honors Projects

This literature review aimed to examine and analyze data to identify causes of disparities in infant mortality rates across West Michigan’s four counties, assess demographic factors influencing infant mortality, and explore cultural practices impacting infant outcomes. A comprehensive review of existing literature, public health data, and community health reports from Allegan, Kent, Muskegon, and Ottawa counties was conducted. Key variables examined included race, maternal age, culture, health literacy, education level, income, insurance coverage, employment status, and marital status. Findings indicate that infant mortality rates vary significantly between counties and are higher among certain racial and socioeconomic groups compared to state …

Sustaining Community Health Through Impactful Snap-Ed Initiatives In Utah, Lacee Jimenez, Kristi Strongo, Lea Palmer, Lendel K. Narine, Heidi Leblanc

Outcomes and Impact Quarterly

Create Better Health (CBH), Utah’s SNAP-Ed program, addresses food insecurity and chronic disease prevention through nutrition education, policy, systems, and environmental (PSE) initiatives, and social media marketing. From 2024 to 2025, CBH reached over 13,500 Utahns through direct education and 81,000 through community interventions. Evaluation results showed significant improvements in nutrition behaviors, including increased fruit and vegetable intake, food resource management, and label use. Follow-up surveys showed sustained behavior change. CBH’s comprehensive approach demonstrates measurable public health impact and points to the importance of continued investment in nutrition education and food access programs to build healthier, food-secure communities.

Incidence Of Health Problems In Australian Mixed Martial Arts And Muay Thai Competitors: A 14-Month Study Of 26 Combat Sports Events, Colin S. Doherty, Oliver R. Barley, Lauren V. Fortington

Research outputs 2022 to 2026

Background: Mixed martial arts (MMA) and Muay Thai (MT) are widely practiced combat sports, yet research on the full spectrum of competition-related health problems (HPs) remains limited, particularly for MT. Existing studies in both sports primarily focus on retrospective analyses of severe injuries, often estimating time lost from training or competition. This study describes the incidence of all competition HPs reported seven days after MMA and MT contests, and determines the number of days impacted by tracking athletes’ self-identified worst HPs until resolution. Methods: Data on competition HPs were collected using an online questionnaire completed seven days after each MMA …

Longitudinal Associations Between Maternal And Child Screen Use At 1 Year Of Age And Child Behavior And Development At 3 Years Of Age, Stephanie Sim, Juliana Zabatiero, Natasha Bear, Amber Beynon, George Thomas, Ravisha Srinivasjois, Brad Jongeling, Desiree Silva, Leon Straker

Research outputs 2022 to 2026

Background: Young children are increasingly exposed to evolving screen technology. International guidelines recommend no screen use for children under the age of 2 years, due to the potential for detrimental effects on behaviour and development. However, evidence for these guidelines is limited by inadequate consideration of device-specific effects (TV and mobile phone/tablet computer), maternal screen use, confounders such as maternal mental health and importance of effect sizes. Our aim was to investigate longitudinal associations of device-specific maternal and child technology use and covariates (including maternal mental health) with behavioural and developmental outcomes, to guide adults on screen use behaviours by …

Sertraline To Reduce Recidivism In Impulsive Violent Offenders (Reinvest): A Randomised Double Blind Clinical Trial, Tony Butler, Emaediong I. Akpanekpo, Lee Knight, Kristy Robledo, David Greenberg, Andrew Ellis, Stephen Allnutt, Kay Wilhelm, Alison Jones, Rodney Scott, Bianca Ton, Luke Grant, Philip Mitchell, Ross Tynan, Jocelyn Jones, Dominic Villa, Duncan Chappell, Carolynn Dixon, Alison Churchill, Val Gebski, Tony Keech, Peter W. Schofield

Research outputs 2022 to 2026

Background: Biological studies suggest serotonin modulation via selective serotonin reuptake inhibitors (SSRIs) might reduce impulsive violence, however, robust evidence in offender populations is limited. We aimed to determine whether sertraline reduces violent reoffending compared with placebo in highly impulsive men with recurrent violent offending.

Methods: We conducted a double-blind, placebo-controlled, randomised clinical trial in community settings in New South Wales, Australia. Eligible participants were men aged 18 years or older with ≥2 prior violent convictions and a Barratt Impulsiveness Scale score ≥70. Following a 4-week single-blind active run-in phase with sertraline, participants were randomly assigned (1:1, minimization stratified by key …