Abstract 119: Initiating Oral Anticoagulation 4 to 14 Days After a Cardioembolic Stroke is Not Associated With a Reduction in Ischemic or Hemorrhagic Events: The IAC Multicenter Cohort

Background/Aims: Guidelines suggest initiating anticoagulation after cardioembolic stroke within 4-14 days from the index event. Data supporting this suggestion did not account for important factors such as infarct burden or early hemorrhagic transformation. Methods: We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with an acute cardioembolic stroke in the setting of atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days) and the primary outcome was the composite endpoint of recurrent stroke/TIA/systemic embolism, symptomatic intracerebral hemorrhage (sICH), or major extracranial hemorrhage (ECH) within 90 days. Results: We enrolled 2090 patients from 8 comprehensive centers in the United States, 1325 met the inclusion criteria (362 were excluded due to non-composite endpoint related death within 90 days, 145 lost to follow up, and 258 were not started on oral anticoagulation or the timing was not reported). Anticoagulation (875 DOAC, 404 Warfarin) was initiated in 0-3 days in 49.7%, 4-14 days in 40.4%, and >14 days in 9.9%. The combined endpoint occurred in 10.7% (142) (98 ischemic events, 21 sICH, and 30 ECH) and did not differ between the three groups: 0-3 days (11.9%), 4-14 days (9.9%), >14 days (9.9%), p=0.525. After adjusting for confounders (such as infarct volume, bridging, CHADS2-Vasc, cardiac thrombus, and hemorrhage on 24-hr imaging), oral anticoagulation timing in the 4-14 day period (vs. >14) was not associated with a reduction in ischemic events (adjusted OR 0.74, p=0.438) and oral anticoagulation timing 4-14 days (vs. 0-3) was not associated with a reduction in sICH (OR 1.28, p=0.638). Factors associated with sICH were bridging (OR 5.36, p=0.001) and hemorrhage on 24-hr imaging (OR 7.26, p<0.001) whereas for ischemic events were warfarin treatment (OR 1.66 95%, p = 0.030) and prior stroke (OR 1.81, p=0.013). Conclusion: In this multicenter real world cohort, the recommended (4-14 days) timeframe to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required determine the optimal timing of anticoagulation initiation.

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Abstract T P139: Rising Rates of the Metabolic Syndrome Among Stroke Survivors in the United States

Stroke ◽

10.1161/str.45.suppl_1.tp139 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Michael McManus ◽

Daniela Markovic ◽

Natalie Valle ◽

Bruce Ovbiagele ◽

Amytis Towfighi

Keyword(s):

United States ◽

Metabolic Syndrome ◽

Stroke Risk ◽

Recurrent Stroke ◽

Temporal Trends ◽

The United States ◽

Self Report ◽

Stroke Survivors ◽

Middle Aged ◽

The Metabolic Syndrome

BACKGROUND: Metabolic syndrome (MetS), a constellation of cardiometabolic risk factors clustering together, affects >47 million US adults and has been independently linked to primary and recurrent stroke risk. Prevalence and trends in MetS among stroke survivors in the United States are unknown. OBJECTIVES: To evaluate recent temporal trends in age and sex-specific MetS prevalence among adults with/without stroke in the US. METHODS: Prevalence of MetS was assessed among fasting adults ≥35 years who participated in National Health and Nutrition Examination Surveys 1999-2010 (n=9,343). Prevalence estimates were weighted to obtain nationally representative estimates (n=430,371,669). MetS was defined by the 2009 harmonized definition. Stroke was determined by self-report. RESULTS: In all groups except men 35-64 years, MetS prevalence was similar among adults with and without stroke in 1999-2002 (Table). MetS prevalence rates were flat from 1999 to 2010 among those without stroke, but increased among stroke survivors, such that up to 80% of men and 86% of women with stroke had MetS, with the greatest rise among the middle-aged. Stroke survivors aged 35-64 years were ~3 times more likely to have MetS than their counterparts without stroke (OR 3.24, 95% CI 1.60-6.55 for men and OR 2.55, 95% CI 1.45-4.50 for women). DISCUSSION: Due to a differential rise in MetS in stroke survivors over the last 10 years, as many as 9 out of 10 stroke survivors now have MetS, suggesting that Mets may increasingly be placing people at risk for stroke. Intensified efforts aimed at identifying and treating MetS, especially among middle-aged individuals, may be warranted to avert stroke risk.

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Anticoagulation Clinics and Self-Testing

Fibrinolytic and Antithrombotic Therapy ◽

10.1093/oso/9780195155648.003.0037 ◽

2006 ◽

Author(s):

Richard C. Becker ◽

Frederick A. Spencer

Keyword(s):

United States ◽

Oral Anticoagulation ◽

Vitamin K Antagonists ◽

Anticoagulation Therapy ◽

The United States ◽

Anticoagulation Clinic ◽

Record Keeping ◽

Self Testing ◽

Model Of Management ◽

Patients At Risk

Oral anticoagulation is a time-tested and effective therapy for patients at risk for thromboembolism (Ansell, 1993). Because of the high risk–benefit ratio of oral vitamin K antagonists, physicians are sometimes reluctant to initiate therapy even for well-established indications (Kutner et al., 1991; McCrory et al., 1995). Furthermore, management is recognized as labor intensive. These factors can be minimized and the benefits of treatment maximized by implementation of an expert model of management that can be achieved with a coordinated and focused system of care known as a coordinated anticoagulation clinic (Ansell and Hughes, 1996). Patient self-testing (and management) may also foster more wide-scale and effective treatment of thromboembolic disorders. The concept of a coordinated anticoagulation clinic (ACC) is not new. Programs focusing on the management of oral anticoagulation have existed in the United States since the late 1950s, and several Scandinavian and other European countries are well known for their coordinated programs (Loeliger et al., 1984), some of which oversee the care of all anticoagulated patients in their respective countries. In the United States, ACCs are growing in number and diversity of services, spurred on by increasing evidence of improved clinical outcomes and cost-effectiveness. The basic elements of a coordinated ACC include (1) a manager or team leader (physician, pharmacist), (2) support staff (nurse practitioner, pharmacist, or physician assistant), (3) standardized record keeping and a computerized database, (4) a manual of operation and practice guidelines, and (5) a formal mechanism for communicating with referring physicians and patients. Currently, most oral anticoagulation therapy in the United States is managed by a patient’s personal physician. In essence, the monitoring and dose titration of patients with thromboembolic disease represents a relatively small proportion of the physician’s overall clinical practice. This approach can be characterized as “traditional” or routine medical care. There may be no specialized system or guidelines in place to track patients or ensure their regular follow-up. An ACC uses a focused and coordinated approach to managing anticoagulation (Ansell et al., 1997).

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LOW USE OF ORAL ANTICOAGULATION IN PATIENTS WITH ATRIAL FIBRILLATION AND RISK FOR STROKE IN THE UNITED STATES

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(16)30887-7 ◽

2016 ◽

Vol 67 (13) ◽

pp. 886 ◽

Cited By ~ 1

Author(s):

Sean Pokorney ◽

Richard Platt ◽

Lisa Ortendahl ◽

Tiffany Woodworth ◽

Noelle Cocoros ◽

...

Keyword(s):

United States ◽

Atrial Fibrillation ◽

Oral Anticoagulation ◽

The United States

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Ethical Calculus for the Provision of Dental Care during and after the COVID-19 Pandemic of 2020

Journal of Dentistry Open Access ◽

10.31487/j.jdoa.2020.01.02 ◽

2020 ◽

pp. 1-3

Author(s):

Akshay Govind ◽

Akshay Govind

Keyword(s):

United States ◽

Return To Work ◽

Dental Care ◽

The United States ◽

Government Support ◽

High Rate ◽

Optimal Timing ◽

Dental Disease ◽

Rate Of Spread ◽

Novel Coronavirus

Background: Due to its high rate of spread and unpredictable course, the COVID-19 virus has limited dentistry to providing only urgent treatment through the pandemic of 2020. With time, the burden of untreated dental disease will slowly rise, but too early a return to elective treatment will contribute to the spread of coronavirus and under-utilize much needed PPE, causing undue morbidity and mortality. Methods: A theoretical framework is proposed for calculating a safe return to work for dental providers in the United States after the COVID-19 pandemic. Clinical, ethical, economic, and mathematical principles are utilized. Results: A model is offered using the concept of QALYs and DALYs to calculate benefits and risks of dental care. The model includes a 13-variable formula that takes into account the prevalence and impact of dental disease and the novel coronavirus. Practical Implications: Organized dentistry groups are encouraged to couple clinicians and policymakers to calculate the optimal timing for a measured return to work. Specifically, a safe return will balance PPE supply and efficacy with hospital capacity to find an optimal prevalence of COVID-19 and dental disease where it would be most responsible for dentists to return to providing elective care. Lastly, a call is made to lobby for government support for dentists, as dental care is a vital service to the public provided almost entirely by a private sector workforce in the United States.

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Abstract TMP13: The Prevalence of Microbleeds in Moyamoya Disease and Moyamoya Syndrome in the United States

Stroke ◽

10.1161/str.47.suppl_1.tmp13 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Mo Chen ◽

Sepand Salehian ◽

Maki Mukawa-Sawada ◽

Marco Pinho ◽

Babu Welch ◽

...

Keyword(s):

United States ◽

Moyamoya Disease ◽

Cerebral Hemorrhage ◽

Hemorrhagic Stroke ◽

Asian Population ◽

The United States ◽

Moyamoya Syndrome ◽

Increased Risk ◽

Ischemic Events

Introduction: Silent cerebral microbleeds (CMB) are common in Moyamoya Disease (MMD) and Moyamoya syndrome (MMS) in Asia. The incidence was reported to be 30-40%. The presence of CMB was found to be a predictor for subsequent cerebral hemorrhage in MMD. The significance of CMB in MMD/MMS in non-Asian population has not been reported. We try to investigate the prevalence of CMB in MMD/MMS in United States and its predictive value for subsequent cerebral hemorrhage. Methods: Moyamoya Database was established in our institution after reviewing patients with ICD9 code of Moyamoya Disease or Moyamoya Syndrome or cerebrovascular occlusive disease from 2007 to 2015. Patients in the database were reviewed retrospectively and included in the study if there were MR images (including GRE, SWI or T2* sequences) at diagnosis or during follow up and available for review. Patients with poor image quality were excluded. Patients were noted to have microbleeds if it was found on initial or follow up MRI. Multivariate logistic regression analysis was used to identify clinical and imaging predictors of CMB. Results: Sixty-three females and fourteen males were included with average age of 39 ± 13 at the time of diagnosis. The majorities were MMD (79.2%) and presented with ischemic events (79.2%). Hemorrhagic stroke was found in 9 (11.7%) patients before diagnosis. Ethnicity included Caucasian (61%), Asian (10.4%), Black (11.7%), and Hispanic (16.9%). Of total 77 patients, 7 (9.1%) had CMB but none of them presented with hemorrhagic stroke. During follow up of average 36 ± 29 months in these 7 patients, no cerebral hemorrhage was reported while ischemic events occurred in 2 (28.6%) patients. Of 70 patients without CMB, 51 had follow up of average 47 ± 46 months. One (2%) had cerebral hemorrhage while 12 (23.5%) had ischemic events. No independent predictors for CMB were identified among age, gender, ethnicity, etiology, presenting stroke, and comorbidities. Conclusions: Silent CMB was less prevalent in MMD/MMS in United States than in Asia. No specific risk factors were identified to be associated with the presence of silent CMB. It was not associated with increased risk of subsequent cerebral hemorrhage in non-Asian population. Further studies are needed to confirm these findings.

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Abstract MP28: Nationwide Racial Disparities in Smoking Cessation After Stroke in the United States

Stroke ◽

10.1161/str.52.suppl_1.mp28 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Neal S Parikh ◽

Melvin Parasram ◽

Yongkang Zhang ◽

Saad Mir ◽

Halina White ◽

...

Keyword(s):

United States ◽

Smoking Cessation ◽

Racial Disparities ◽

Race And Ethnicity ◽

Recurrent Stroke ◽

The United States ◽

Smoking History ◽

Behavioral Risk ◽

Stroke Survivors ◽

Cross Sectional

Introduction: Black Americans face a higher risk of recurrent stroke than White Americans, and the reasons are unclear. Smoking after stroke is associated with a higher risk of recurrence. We investigated whether there are racial disparities in smoking cessation among stroke survivors in the United States. Methods: We performed a cross-sectional analysis of data from the Centers for Disease Control and Prevention Behavioral Risk Factor Surveillance System, an annual, nationally representative health survey. Respondents are asked about medical conditions and health-related behaviors. We pooled data from 2013-2018, during which race and ethnicity were uniformly reported. We included respondents with prior stroke and any smoking history. The exposure was self-reported race, and the outcome was smoking cessation. We calculated the quit ratio, defined as the proportion of former smokers among ever smokers; this is a standard measure in population-based studies of smoking cessation. Survey procedures were used to estimate frequencies and summarize quit ratios by race. Multiple logistic regression was used to assess the association of Black race with smoking cessation, as compared to White race, while adjusting for age, gender, Hispanic ethnicity, education, income, health insurance, and the number of smoking-related health conditions (heart disease, lung disease, cancer) that may prompt cessation. Results: Among 4,374,011 Americans with a history of stroke and any smoking, the median age was 67 years (IQR, 58-76), and 45.7% were women; 15.4% were Black, 74.8% were White, and 9.8% reported other race. The crude quit ratio was 51.4% (95% CI, 49.0-53.7) in Black and 63.2% (95% CI, 62.4-64.1) in White stroke survivors. In unadjusted analyses, Black stroke survivors were less likely to have quit smoking than White stroke survivors (OR, 0.61; 95% CI, 0.55-0.68). This remained the case after accounting for differences in demographics and smoking-related comorbidities (OR, 0.85; 95% CI, 0.74-0.98). Conclusion: In this nationwide study, Black stroke survivors had lower smoking quit rates than White stroke survivors, even after accounting for group differences. Expanding access to smoking-cessation interventions may reduce disparities in recurrent stroke.

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Effectiveness of Prenatal Tdap Immunization in the Prevention of Infant Pertussis in the United States

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx162.163 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S68-S68

Author(s):

Sylvia Becker-Dreps ◽

Anne M Butler ◽

Leah J McGrath ◽

Kim A Boggess ◽

David J Weber ◽

...

Keyword(s):

United States ◽

Pregnant Women ◽

Gestational Age ◽

Clinical Effectiveness ◽

The United States ◽

Optimal Timing ◽

Third Trimester ◽

The Third ◽

Control And Prevention ◽

Insurance Claims Data

Abstract Background The Centers for Disease Control and Prevention recommends that all pregnant women in the United States receive tetanus-diphtheria-acellular pertussis (Tdap) immunization to prevent infant pertussis. While the vaccine may be administered at any time during pregnancy, the recommendations define administration at 27 to 36 weeks of gestation as optimal timing to prevent infant pertussis. These recommendations were primarily based on immunogenicity studies. The objective of this study was to examine the clinical effectiveness of prenatal Tdap, and to understand whether effectiveness varies by gestational age at immunization. Methods We performed a nationwide cohort study of pregnant women with deliveries in 2010–2014 and their infants. Commercial insurance claims data were used to identify receipt of Tdap immunization in the pregnant women, and hospitalizations and outpatient visits for pertussis in their infants until 18 months of age. To address the difficulties in diagnosing pertussis, we also employed a “probable pertussis” definition, as an inpatient or outpatient diagnosis of pertussis, plus antibiotic treatment with a macrolide or trimethoprim/sulfamethoxazole within 7 days of diagnosis. Pertussis occurrence was compared between infants of mothers who received prenatal Tdap (overall, and stratified by gestational age at administration) and infants of unvaccinated mothers. Results There were 675,167 mother–infant pairs included in the cohort. Among infants whose mothers received Tdap at any time during pregnancy, the rate of pertussis hospitalization was 50% lower (adjusted hazards ratio (HR) = 0.50, 95% CI: 0.23, 1.09), and the rate of probable pertussis was 42% lower (HR = 0.58, 95% CI: 0.38, 0.89) than infants of unimmunized mothers. Pertussis rates were also lower for infants whose mothers received prenatal Tdap during the third trimester. Infants whose mothers received Tdap before the third trimester also tended to have lower rates of pertussis, but these estimates were imprecise. Conclusion Infants of mothers who received prenatal Tdap experienced half the rate of pertussis as compared with infants of unimmunized mothers. Our results do not provide evidence to support changing the currently recommended timing of Tdap administration in pregnancy. Disclosures S. Becker-Dreps, Pfizer: Consultant and Grant Investigator, Consulting fee and Research grant; A. M. Butler, Astra Zeneca: Consultant, Support to institution; Amgen: Grant Investigator, Investigator initiated grant to institution;  D. J. Weber, Merck: Consultant and Speaker’s Bureau, Consulting fee and Speaker honorarium; Pfizer: Consultant, Consulting fee; J. B. Layton, Merck: Member of Center for Pharmacoepidemiology, Support to institution; GlaxoSmithKline: Member of Center for Pharmacoepidemiology, Support to institution; UCB Biosciences: Member of Center for Pharmacoepidemiology, Support to institution

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A visit to the stroke belt of the United States

Journal of Neurosciences in Rural Practice ◽

10.4103/0976-3147.102653 ◽

2012 ◽

Vol 03 (03) ◽

pp. 426-428

Author(s):

Lokesh Bathala

Keyword(s):

United States ◽

Recurrent Stroke ◽

Recombinant Tissue Plasminogen Activator ◽

The United States ◽

Southeastern Part ◽

Stroke Treatment ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Diagnostic Catheter ◽

Stroke Belt

ABSTRACTSoutheastern part of United States has been called the Stroke Belt due to a much higher incidence of stroke compared to the rest of the country. In this article, I summarize my 2 weeks of observations as a clinical preceptor at the Comprehensive Stroke Center, University of Alabama Hospital, Birmingham, AL. 57 patients were admitted during these 2 weeks, 61% had ischemic strokes, and 23% received intravenous recombinant tissue plasminogen activator (IV rt-PA). Endovascular neuro-interventionalists were performing diagnostic catheter angiography in 14% and emergent revascularization procedures in 7% of consecutive patients. Also, the stroke team enrolled 6 patients into National institute of health (NIH) funded clinical trials (3 Argatroban tPA stroke study (ARTSS), 2 Safety study of external counter pulsation as a treatment for acute ischemic stroke (CUFFS), 1 stenting and aggressive medical management for preventing recurrent stroke in intracranial stenosis (SAMMPRIS). In my opinion, these observations provided me with useful knowledge how to develop a cutting edge, proactive stroke treatment system. In particular, availability 24 × 7 and consistent application of a curative, “finding reasons to treat approach” coupled with state-of the-art technologies and skilled operators could make a huge difference.

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Abstract P713: Early Apixaban Therapy After Ischemic Stroke in Patients With Atrial Fibrillation

Stroke ◽

10.1161/str.52.suppl_1.p713 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Anas Alrohimi ◽

Brian H Buck ◽

Glen Jickling ◽

Ashfaq Shuaib ◽

Sibi Thirunavukkarasu ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Infarct Volume ◽

Hemorrhagic Transformation ◽

Performance Criteria ◽

Optimal Timing ◽

Open Label ◽

Stroke Study ◽

Ischemic Events

Background: The optimal timing of anticoagulation after stroke in patients with atrial fibrillation (AF) is unknown. Patients and methods: A prospective, open label study (NCT04435418) of patients with AF treated with apixaban within 14 days of ischemic stroke/TIA onset was conducted. Baseline and follow-up CT scans were assessed for hemorrhagic transformation (HT) and graded using European Cooperative Acute Stroke Study (ECASS) criteria. The primary endpoint was symptomatic HT. Incident HT rates were assessed as Objective Performance Criteria. Results: One-hundred AF stroke patients, with a mean age of 79±11 years were enrolled. Median infarct volume was 4 (0.5-10.75) ml. Median time from index event onset to apixaban initiation was 2 (1-6) days, and median baseline NIHSS was 4 (1-9). Asymptomatic HT on baseline imaging was present in 15 patients. Infarct volume (OR= 1.1, [1.02-1.12], P <0.0001) and NIHSS (OR= 1.11, [1.03-1.20], P =0.007) were both associated with baseline HT. No patients developed symptomatic HT or systemic hemorrhage. Incident asymptomatic HT was seen on follow-up CT scan in 3 patients. Patients with incident HT were functionally independent (mRS=0-2) at 90 days. Recurrent ischemic events occurred within 90 days in 13 patients, 4 of which were associated with severe disability (mRS 3-5) and 4 with death. Discussion: Early apixaban treatment did not precipitate symptomatic HT after stroke. All HT was asymptomatic identified on imaging. Recurrent ischemic events were common and clinically symptomatic. Conclusions: Symptomatic HT rates are likely to be low in randomized trials of DOAC initiation post-stroke. Recurrent ischemic stroke may be the major clinical outcome.

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A Multistage Stochastic Programming Approach to the Optimal Surveillance and Control of the Emerald Ash Borer in Cities

INFORMS Journal on Computing ◽

10.1287/ijoc.2020.0963 ◽

2020 ◽

Author(s):

Eyyüb Y. Kıbış ◽

İ. Esra Büyüktahtakın ◽

Robert G. Haight ◽

Najmaddin Akhundov ◽

Kathleen Knight ◽

...

Keyword(s):

United States ◽

Cutting Planes ◽

Emerald Ash Borer ◽

Cutting Plane ◽

The United States ◽

Mixed Integer ◽

Optimal Timing ◽

Stochastic Mixed Integer Programming ◽

Ash Trees ◽

And Control

Emerald ash borer (EAB), a wood-boring insect native to Asia and invading North America, has killed untold millions of high-value ash trees that shade streets, homes, and parks and caused significant economic damage in cities of the United States. Local actions to reduce damage include surveillance to find EAB and control to slow its spread. We present a multistage stochastic mixed-integer programming (M-SMIP) model for the optimization of surveillance, treatment, and removal of ash trees in cities. Decision-dependent uncertainty is modeled by representing surveillance decisions and the realizations of the uncertain infestation parameter contingent on surveillance as branches in the M-SMIP scenario tree. The objective is to allocate resources to surveillance and control over space and time to maximize public benefits. We develop a new cutting-plane algorithm to strengthen the M-SMIP formulation and facilitate an optimal solution. We calibrate and validate our model of ash dynamics using seven years of observational data and apply the optimization model to a possible infestation in Burnsville, Minnesota. Proposed cutting planes improve the solution time by an average of seven times over solving the original M-SMIP model without cutting planes. Our comparative analysis shows that the M-SMIP model outperforms six different heuristic approaches proposed for the management of EAB. Results from optimally solving our M-SMIP model imply that under a belief of infestation, it is critical to apply surveillance immediately to locate EAB and then prioritize treatment of minimally infested trees followed by removal of highly infested trees. Summary of Contributions: Emerald ash borer (EAB) is one of the most damaging invasive species ever to reach the United States, damaging millions of ash trees. Much of the economic impact of EAB occurs in cities, where high-value ash trees grow in abundance along streets and in yards and parks. This paper addresses the joint optimization of surveillance and control of the emerald ash borer invasion, which is a novel application for the INFORMS society because, to our knowledge, this specific problem of EAB management has not been published before in any OR/MS journals. We develop a new multi-stage stochastic mixed-integer programming (MSS-MIP) formulation, and we apply our model to surveillance and control of EAB in cities. Our MSS-MIP model aims to help city managers maximize the net benefits of their healthy ash trees by determining the optimal timing and target population for surveying, treating, and removing infested ash trees while taking into account the spatio-temporal stochastic growth of the EAB infestation. We develop a new cutting plane methodology motivated by our problem, which could also be applied to other stochastic MIPs. Our cutting plane approach provides significant computational benefit in solving the problem. Specifically, proposed cutting planes improve the solution time by an average of seven times over solving the original M-SMIP model without cutting planes. We calibrate and validate our model using seven years of ash infestation observations in forests near Toledo, Ohio. We then apply our model to an urban forest in Burnsville, Minnesota, that is threatened by EAB. Our results provide insights into the optimal timing and location of EAB surveillance and control strategies.

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