Trends in incidence, health care consumption, and costs for proximal femoral fractures in the Netherlands between 2000 and 2019: a nationwide study.

This study evaluated the incidence rates and societal burden of hip fractures in The Netherlands. Although incidence in the elderly population is decreasing and hospital stay is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population. PURPOSE: The aim of this nationwide study was to provide an overview of the incidence rate and economic burden of acute femoral neck and trochanteric fractures in The Netherlands. METHODS: Data of patients who sustained acute proximal femoral fractures in the period January 1, 2000, to December 31, 2019, were extracted from the National Medical Registration of the Dutch Hospital Database. The incidence rate, hospital length of stay (HLOS), health care and lost productivity costs, and years lived with disability (YLD) were calculated for age- and sex-specific groups. RESULTS: A total of 357,073 patients were included. The overall incidence rate increased by 22% over the 20-year study period from 16.4 to 27.1/100,000 person-years (py). The age-specific incidence rate in elderly > 65 years decreased by 16% (from 649.1 to 547.6/100,000 py). The incidence rate in men aged > 90 has surpassed the incidence rate in women. HLOS decreased in all age groups, hip fracture subtypes, and sexes from a mean of 18.5 to 7.2 days. The mean health care costs, over the 2015-2019 period, were lower for men (€17,723) than for women (€23,351) and increased with age to €26,639 in women aged > 80. Annual cumulative costs reached €425M, of which 73% was spent on women. CONCLUSION: The total incidence of hip fractures in The Netherlands has increased by 22%. Although incidence in the elderly population is decreasing and HLOS is at an all-time low, the burden of medical costs and crude numbers of proximal femoral fractures are still rising in our aging population.

Trauma models to identify major trauma and mortality in the prehospital setting.

BACKGROUND: Patients with major trauma might benefit from treatment in a trauma centre, but early identification of major trauma (Injury Severity Score (ISS) over 15) remains difficult. The aim of this study was to undertake an external validation of existing prognostic models for injured patients to assess their ability to predict mortality and major trauma in the prehospital setting. METHODS: Prognostic models were identified through a systematic literature search up to October 2017. Injured patients transported by Emergency Medical Services to an English hospital from the Trauma Audit and Research Network between 2013 and 2016 were included. Outcome measures were major trauma (ISS over 15) and in-hospital mortality. The performance of the models was assessed in terms of discrimination (concordance index, C-statistic) and net benefit to assess the clinical usefulness. RESULTS: A total of 154 476 patients were included to validate six previously proposed prediction models. Discriminative ability ranged from a C-statistic value of 0·602 (95 per cent c.i. 0·596 to 0·608) for the Mechanism, Glasgow Coma Scale, Age and Arterial Pressure model to 0·793 (0·789 to 0·797) for the modified Rapid Emergency Medicine Score (mREMS) in predicting in-hospital mortality (11 882 patients). Major trauma was identified in 52 818 patients, with discrimination from a C-statistic value of 0·589 (0·586 to 0·592) for mREMS to 0·735 (0·733 to 0·737) for the Kampala Trauma Score in predicting major trauma. None of the prediction models met acceptable undertriage and overtriage rates. CONCLUSION: Currently available prehospital trauma models perform reasonably in predicting in-hospital mortality, but are inadequate in identifying patients with major trauma. Future research should focus on which patients would benefit from treatment in a major trauma centre.

ANTECEDENTES: Los pacientes con traumatismo mayor pueden beneficiarse del tratamiento en un centro de trauma, pero la identificación precoz del traumatismo mayor (Injury Severity Score, ISS > 15) sigue siendo difícil. El objetivo de este estudio fue validar externamente los modelos pronósticos existentes para los pacientes con traumatismos con el fin de evaluar su capacidad para predecir el traumatismo mayor y la mortalidad en el entorno pre-hospitalario. MÉTODOS: Los modelos pronóstico se identificaron mediante una búsqueda sistemática de la literatura hasta octubre de 2017. Los pacientes incluidos fueron pacientes con traumatismos que fueron trasladados mediante los servicios de emergencia médica (emergency medical services, EMS) a un hospital inglés perteneciente a Trauma Audit and Research Network (TARN) entre 2013 y 2016. Las variables evaluadas fueron los traumatismos graves (ISS > 15) y la mortalidad hospitalaria. El rendimiento de los modelos se analizó en términos de discriminación (índice de concordancia, c) y de beneficio neto para evaluar la utilidad clínica. RESULTADOS: Se incluyeron un total de 154.476 pacientes para validar los seis modelos de predicción propuestos previamente. La capacidad discriminatoria osciló entre c = 0,602 (i.c. del 95%: 0,596-0,608) para el modelo que incluye mecanismo, escala de coma de Glasgow, edad y presión arterial (MGAP) hasta c = 0,793 (0,789-0,797) para la puntuación de medicina de emergencia rápida modificada (mREMS) en la predicción de la mortalidad hospitalaria (n = 11.882). Se identificó un traumatismo mayor en 52.818 pacientes, con una discriminación de c = 0,589 (0,586-0,592) para mREMS a c = 0,735 (0,733-0,737) para la puntuación de trauma de Kampala en la predicción de traumatismo mayor. Ninguno de los modelos de predicción cumplió con las tasas aceptables de subtriaje (undertriage) y sobretriaje (overtriage). CONCLUSIÓN: Los modelos de trauma pre-hospitalarios actualmente disponibles tienen un rendimiento razonable para predecir la mortalidad hospitalaria, pero son inadecuados para identificar a los pacientes con traumatismo mayor. En el futuro, las investigaciones deberían centrarse en identificar a los pacientes que se podrían beneficiar del tratamiento en un centro de trauma especializado.

Emergency Bleeding Control Interventions After Immediate Total-Body CT Scans in Trauma Patients.

BACKGROUND: Immediate total-body CT (iTBCT) is often used for screening of potential severely injured patients. Patients requiring emergency bleeding control interventions benefit from fast and optimal trauma screening. The aim of this study was to assess whether an initial trauma assessment with iTBCT is associated with lower mortality in patients requiring emergency bleeding control interventions. METHODS: In the REACT-2 trial, patients who sustained major trauma were randomized for iTBCT or for conventional imaging and selective CT scanning (standard workup; STWU) in five trauma centers. Patients who underwent emergency bleeding control interventions following their initial trauma assessment with iTBCT were compared for mortality and clinically relevant time intervals to patients that underwent the initial trauma assessment with the STWU. RESULTS: In the REACT-2 trial, 1083 patients were enrolled of which 172 (15.9%) underwent emergency bleeding control interventions following their initial trauma assessment. Within these 172 patients, 85 (49.4%) underwent iTBCT as primary diagnostic modality during the initial trauma assessment. In trauma patients requiring emergency bleeding control interventions, in-hospital mortality was 12.9% (95% CI 7.2-21.9%) in the iTBCT group compared to 24.1% (95% CI 16.3-34.2%) in the STWU group (p = 0.059). Time to bleeding control intervention was not reduced; 82 min (IQR 5-121) versus 98 min (IQR 62-147), p = 0.108. CONCLUSIONS: Reduction in mortality in trauma patients requiring emergency bleeding control interventions by iTBCT could not be demonstrated in this study. However, a potentially clinically relevant absolute risk reduction of 11.2% (95% CI - 0.3 to 22.7%) in comparison with STWU was observed. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01523626.

Measurements of Impurity Transport Due to Drift-Wave Turbulence in a Toroidal Plasma.

The first direct measurements of an impurity particle flux driven by drift-wave turbulence in a toroidal magnetized plasma are reported. The correlation between the impurity density and radial velocity fluctuations is measured using ion Doppler spectroscopy. The small, very fast radial velocity fluctuation is resolved with the aid of a new linearized spectrum correlation analysis method that rejects uncorrelated noise as the sample size increases. The measured C^{2+} turbulent impurity flux in the edge of the plasma is directed inward and is consistent with impurity density measurements. This is also the first direct evidence for fluctuation-induced transport due to trapped-electron-mode turbulence in reversed field pinch plasmas.

Kinetic stress and intrinsic flow in a toroidal plasma.

A new mechanism for intrinsic plasma flow has been experimentally identified in a toroidal plasma. For reversed field pinch plasmas with a few percent ß (ratio of plasma pressure to magnetic pressure), measurements show that parallel pressure fluctuations correlated with magnetic fluctuations create a kinetic stress that can affect momentum balance and the evolution of intrinsic plasma flow. This implies kinetic effects are important for flow generation and sustainment.

Comparing health status after major trauma across different levels of trauma care.

INTRODUCTION: Mortality due to trauma has reduced the past decades. Trauma network implementations have been an important contributor to this achievement. Besides mortality, patient reported outcome parameters should be included in evaluation of trauma care. While concentrating major trauma care, hospitals are designated with a certain level of trauma care following specific criteria. OBJECTIVE: Comparing health status of major trauma patients after two years across different levels of trauma care in trauma networks. METHODS: Multicentre observational study comprising a secondary longitudinal multilevel analysis on prospective cohorts from two neighbouring trauma regions in the Netherlands. INCLUSION CRITERIA: patient aged ≥ 18 with an ISS > 15 surviving their injuries at least one year after trauma. Health status was measured one and two years after trauma by EQ-5D-5 L, added with a sixth health dimension on cognition. Level I trauma centres were considered as reference in uni- and multivariate analysis. RESULTS: Respondents admitted to a level I trauma centre scored less favourable EQ-US and EQ-VAS in both years (0.81-0.81, 71-75) than respondents admitted to a level II (0.88-0.87, 78-85) or level III (0.89-0.88, 75-80) facility. Level II facilities scored significantly higher EQ-US and EQ-VAS in time for univariate analysis (ß 0.095, 95% CI 0.038-0.153, p = 0.001, and ß 7.887, 95% CI 3.035-12.740, p = 0.002), not in multivariate analysis (ß 0.052, 95% CI -0.010-0.115, p = 0.102, and ß 3.714, 95% CI -1.893-9.321, p = 0.193). Fewer limitations in mobility (OR 0.344, 95% CI 0.156-0.760), self-care (OR 0.219, 95% CI 0.077-0.618), and pain and discomfort (OR 0.421, 95% CI 0.214-0.831) remained significant for level II facilities in multivariate analysis, whereas significant differences with level III facilities disappeared. CONCLUSION: Major trauma patients admitted to level I trauma centres reported a less favourable general health status and more limitations compared to level II and III facilities scoring populations norms one to two years after trauma. Differences on general health status and limitations in specific health domains disappeared in adjusted analysis. Well-coordinated trauma networks offer homogeneous results for all major trauma patients when they are distributed in different centres according to their need of care.

Accuracy of an expanded early warning score for patients in general and trauma surgery wards.

BACKGROUND: Early warning scores (EWS) may aid the prediction of major adverse events in hospitalized patients. Recently, an expanded EWS was introduced in the Netherlands. The aim of this study was to assess the relationship between this EWS and the occurrence of major adverse clinical events during hospitalization of patients admitted to a general and trauma surgery ward. METHODS: This was a prospective cohort study of consecutive patients admitted to the general and trauma surgery ward of a university medical centre (March-September 2009). Follow-up was limited to the time the patient was hospitalized. Logistic regression analysis was used to assess the relationship between the EWS and the occurrence of the composite endpoint consisting of death, reanimation, unexpected intensive care unit admission, emergency surgery and severe complications. Performance of the EWS was analysed using sensitivity, specificity, predictive values and receiver operating characteristic (ROC) curves. RESULTS: A total of 572 patients were included. During a median follow-up of 4 days, 46 patients (8.0 per cent) reached the composite endpoint (two deaths, two reanimations, 17 intensive care unit admissions, 44 severe complications, one emergency operation). An EWS of at least 3, adjusted for baseline American Society of Anesthesiology classification, was associated with a significantly higher risk of reaching the composite endpoint (odds ratio 11·3, 95 per cent confidence interval (c.i.) 5·5 to 22·9). The area under the ROC curve was 0·87 (95 per cent c.i. 0·81 to 0·93). When considering an EWS of at least 3 to be a positive test result, sensitivity was 74 per cent and specificity was 82 per cent. CONCLUSION: An EWS of 3 or more is an independent predictor of major adverse events in patients admitted to a general and trauma surgery ward.

Classical impurity ion confinement in a toroidal magnetized fusion plasma.

High-resolution measurements of impurity ion dynamics provide first-time evidence of classical ion confinement in a toroidal, magnetically confined plasma. The density profile evolution of fully stripped carbon is measured in MST reversed-field pinch plasmas with reduced magnetic turbulence to assess Coulomb-collisional transport without the neoclassical enhancement from particle drift effects. The impurity density profile evolves to a hollow shape, consistent with the temperature screening mechanism of classical transport. Corroborating methane pellet injection experiments expose the sensitivity of the impurity particle confinement time to the residual magnetic fluctuation amplitude.

Electron temperature and density measurement by Thomson scattering with a high repetition rate laser of 20 kHz on LHD.

Thomson scattering measurements with a high-repetition-rate laser have commenced in the Large Helical Device. As an example of the fast phenomena captured by this diagnostic system, measurements at a 20 kHz repetition-rate in hydrogen pellet-injected plasmas are presented. Signal processing methods for this measurement have been developed and electron temperature profiles with almost 70 spatial points were evaluated at time intervals of 50 [Formula: see text]s. After Raman scattering calibration, electron density profiles were derived. Fast changes in the electron temperature and density profiles within 1 ms were observed.

Design study of an edge current density diagnostic using new high-performance single-channel beam emission spectrometers at DIII-D.

A novel Motional Stark Effect spectroscopy system has been designed for application at the DIII-D tokamak. The system is optimized for studies of the poloidal and toroidal magnetic field in the plasma pedestal region with frame rates of up to 10 kHz. Light from an existing high-photon-throughput collection lens is analyzed using four single-channel f/2.8 Czerny-Turner spectrometers that use custom-made lens systems instead of mirrors. Each spectrometer has two separate outgoing legs and is operated in a positive grating order, which allows for simultaneous observations of D-alpha and D-beta spectra. Forward modeling using the code FIDASIM shows a radial resolution of the system close to 0.6 cm and sufficiently good spectral resolution when masking the high throughput light collection lens in the horizontal direction to avoid overly strong Doppler broadening of beam emission lines. Moreover, a detailed sensitivity study considering realistic levels of readout and photon noise shows that the poloidal and toroidal magnetic field strengths can be inferred with an uncertainty of less than 1%, which will allow the inference of changes of the plasma current during transient events.

Conceptual design and performance predictions for 2D beam emission spectroscopy turbulence measurements at Wendelstein 7-X.

A conceptual design for a 2D beam emission spectroscopy diagnostic system to measure ion gyro-scale plasma turbulence at Wendeslstein 7-X is described. The conceptual design identifies field-aligned viewing geometries and ports for cross-field turbulence measurements in the neutral beam volume. A 2D sightline grid covers the outer plasma region, and the grid configuration provides sufficient k-space coverage in radial and poloidal directions for ion temperature gradient and trapped-electron mode turbulence measurements. Emission intensity estimates, optical transmission losses, and detector noise levels indicate that the measurements will be sensitive to plasma density fluctuations as small as δn/n ≈ 0.5% with a bandwidth of 1 MHz. Implementation challenges include a small beam emission Doppler shift due to nearly radial heating beams and reduced optical throughput due to collection aperture limitations.

Preceding propagation of turbulence pulses at avalanche events in a magnetically confined plasma.

The preceding propagation of turbulence pulses has been observed for the first time in heat avalanche events during the collapse of the electron internal transport barrier (e-ITB) in the Large Helical Device. The turbulence and heat pulses are generated near the foot of the e-ITB and propagate to the peripheral region within a much shorter time than the diffusion timescale. The propagation speed of the turbulence pulse is approximately 10 km/s, which is faster than that of the heat pulse propagating at a speed of 1.5 km/s. The heat pulse propagates at approximately the same speed as that in the theoretical prediction, whereas the turbulence pulse propagates one order of magnitude faster than that in the prediction, thereby providing important insights into the physics of non-local transport.

Experimental evidence for a reduction in electron thermal diffusion due to trapped particles.

New high time resolution measurements of the electron thermal diffusion χ(e) throughout the sawtooth cycle of the Madison Symmetric Torus reversed-field pinch have been made by utilizing the enhanced capabilities of the upgraded multipoint, multipulse Thomson scattering system. These measurements are compared to the χ(e) due to magnetic diffusion predicted by using information from a new high spectral resolution zero-ß nonlinear resistive magnetohydrodynamic simulation performed, for the first time, at the Lundquist number of high current Madison Symmetric Torus plasmas (S≈4×10(6)). Agreement between the measured and predicted values is found only if the reduction in thermal diffusion due to trapped particles is taken into account.

Anisotropic ion heating and tail generation during tearing mode magnetic reconnection in a high-temperature plasma.

Complementary measurements of ion energy distributions in a magnetically confined high-temperature plasma show that magnetic reconnection results in both anisotropic ion heating and the generation of suprathermal ions. The anisotropy, observed in the C(+6) impurity ions, is such that the temperature perpendicular to the magnetic field is larger than the temperature parallel to the magnetic field. The suprathermal tail appears in the majority ion distribution and is well described by a power law to energies 10 times the thermal energy. These observations may offer insight into the energization process.

Robust analysis of space-, time-, and energy-resolved soft x-ray measurements of magnetically confined fusion plasmas (invited).

A novel compact multi-energy soft x-ray (ME-SXR) diagnostic based on the PILATUS3 100K x-ray detector has been developed in collaboration between the Princeton Plasma Physics Laboratory and the University of Wisconsin-Madison and tested on the Madison Symmetric Torus (MST) reversed-field pinch. This solid-state photon-counting detector consists of a two-dimensional array of ∼100 000 pixels for which the lower photon absorption cutoff energy can be independently set, allowing it to be configured for a unique combination of simultaneous spatial, spectral, and temporal resolution of ∼1 cm, 100 eV, and 500 Hz, respectively. The diagnostic is highly versatile and can be readily adapted to diverse plasma operating conditions and scientific needs without any required downtime. New results from improved-confinement and quasi-single helicity plasmas in the MST demonstrate how the detector can be applied to study multiple aspects of the evolution of magnetically confined fusion-grade plasmas. These include observing the evolution of thermal emissivity, characterizing the energy of mid-Z excitation lines, extracting the Te profile, and observing the evolution of non-thermal populations. A technique for integrating the ME-SXR diagnostic into an integrated data analysis framework based on Bayesian inference is also presented. This allows ME-SXR measurements to be combined with data for complementary diagnostics in order to simultaneously infer Te and nZ from all available information.

Microcalorimeter measurement of x-ray spectra from a high-temperature magnetically confined plasma.

A NASA-built x-ray microcalorimeter spectrometer has been installed on the MST facility at the Wisconsin Plasma Physics Laboratory and has recorded x-ray photons emitted by impurity ions of aluminum in a majority deuterium plasma. Much of the x-ray microcalorimeter development has been driven by the needs of astrophysics missions, where imaging arrays with few-eV spectral resolution are required. The goal of our project is to adapt these single-photon-counting microcalorimeters for magnetic fusion energy research and demonstrate the value of such measurements for fusion science. Microcalorimeter spectrometers combine the best characteristics of the x-ray instrumentation currently available on fusion devices: high spectral resolution similar to an x-ray crystal spectrometer and the broadband coverage of an x-ray pulse height analysis system. Fusion experiments are increasingly employing high-Z plasma-facing components and require measurement of the concentration of all impurity ion species in the plasma. This diagnostic has the capability to satisfy this need for multi-species impurity ion data and will also contribute to measurements of impurity ion temperature and flow velocity, Zeff, and electron density. Here, we introduce x-ray microcalorimeter detectors and discuss the diagnostic capability for magnetic fusion energy experiments. We describe our experimental setup and spectrometer operation approach at MST, and we present the results from an initial measurement campaign.

Multi-energy reconstructions, central electron temperature measurements, and early detection of the birth and growth of runaway electrons using a versatile soft x-ray pinhole camera at MST.

A multi-energy soft x-ray pinhole camera has been designed, built, and deployed at the Madison Symmetric Torus to aid the study of particle and thermal transport, as well as MHD stability physics. This novel imaging diagnostic technique employs a pixelated x-ray detector in which the lower energy threshold for photon detection can be adjusted independently on each pixel. The detector of choice is a PILATUS3 100 K with a 450 µm thick silicon sensor and nearly 100 000 pixels sensitive to photon energies between 1.6 and 30 keV. An ensemble of cubic spline smoothing functions has been applied to the line-integrated data for each time-frame and energy-range, obtaining a reduced standard-deviation when compared to that dominated by photon-noise. The multi-energy local emissivity profiles are obtained from a 1D matrix-based Abel-inversion procedure. Central values of Te can be obtained by modeling the slope of the continuum radiation from ratios of the inverted radial emissivity profiles over multiple energy ranges with no a priori assumptions of plasma profiles, magnetic field reconstruction constraints, high-density limitations, or need of shot-to-shot reproducibility. In tokamak plasmas, a novel application has recently been tested for early detection, 1D imaging, and study of the birth, exponential growth, and saturation of runaway electrons at energies comparable to 100 × Te,0; thus, early results are also presented.

Simple elbow dislocations: a systematic review of the literature.

OBJECTIVE: To identify if functional treatment is the best available treatment for simple elbow dislocations. SEARCH STRATEGY: Electronic databases MEDLINE, EMBASE, LILACS, and the Cochrane Central Register of Controlled Trials. SELECTION CRITERIA: Studies were eligible for inclusion if they were trials comparing different techniques for the treatment of simple elbow dislocations. DATA ANALYSIS: Results were expressed as relative risk for dichotomous outcomes and weighted mean difference for continuous outcomes with 95% confidence intervals. MAIN RESULTS: This review has included data from two trials and three observational comparative studies. Important data were missing from three observational comparative studies and the results from these studies were extracted for this review. No difference was found between surgical treatment of the collateral ligaments and plaster immobilisation of the elbow joint. Better range of movement, less pain, better functional scores, shorter disability and shorter treatment time were seen after functional treatment versus plaster immobilisation.

The Dutch nationwide trauma registry: The value of capturing all acute trauma admissions.

INTRODUCTION: Twenty years ago the Dutch trauma care system was reformed by the designating 11 level one Regional trauma centres (RTCs) to organise trauma care. The RTCs set up the Dutch National Trauma Registry (DNTR) to evaluate epidemiology, patient distribution, resource use and quality of care. In this study we describe the DNTR, the incidence and main characteristics of Dutch acutely admitted trauma patients, and evaluate the value of including all acute trauma admissions compared to more stringent criteria applied by the national trauma registries of the United Kingdom and Germany. METHODS: The DNTR includes all injured patients treated at the ED within 48 hours after trauma and consecutively followed by direct admission, transfers to another hospital or death at the ED. DNTR data on admission years 2007-2018 were extracted to describe the maturation of the registry. Data from 2018 was used to describe the incidence rate and patient characteristics. Inclusion criteria of the Trauma Audit and Research (TARN) and the Deutsche Gesellschaft für Unfallchirurgie (DGU) were applied on 2018 DNTR data. RESULTS: Since its start in 2007 a total of 865,460 trauma cases have been registered in the DNTR. Hospital participation increased from 64% to 98%. In 2018, a total of 77,529 patients were included, the median age was 64 years, 50% males. Severely injured patients with an ISS≥16, accounted for 6% of all admissions, of which 70% was treated at designated RTCs. Patients with an ISS≤ 15were treated at non-RTCs in 80% of cases. Application of DGU or TARN inclusion criteria, resulted in inclusion of respectively 5% and 32% of the DNTR patients. Particularly children, elderly and patients admitted at non-RTCs are left out. Moreover, 50% of ISS≥16 and 68% of the fatal cases did not meet DGU inclusion criteria CONCLUSION: The DNTR has evolved into a comprehensive well-structured nationwide population-based trauma register. With 80,000 inclusions annually, the DNTR has become one of the largest trauma databases in Europe The registries strength lies in the broad inclusion criteria which enables studies on the burden of injury and the quality and efficiency of the entire trauma care system, encompassing all trauma-receiving hospitals.

Using integrated data analysis to extend measurement capability (invited).

The analysis approach called integrated data analysis (IDA) provides a means to exploit all information present in multiple streams of raw data to produce the best inference of a plasma parameter. This contrasts with the typical approach in which information (data) from a single diagnostic is used to measure a given parameter, e.g., visible bremsstrahlung → Z eff. Data from a given diagnostic usually contain information on many parameters. For example, a Thomson scattering diagnostic is sensitive to bremsstrahlung and line emission in addition to electron temperature. This background light is typically subtracted off and discarded but could be used to improve knowledge of Z eff. IDA encourages explicit awareness of such information and provides the quantitative framework to exploit it. This gives IDA the ability to increase spatial and temporal resolution, increase precision and accuracy of inferences, and measure plasma parameters that are difficult or impossible to measure using single diagnostic techniques. One example is the measurement of Z eff on Madison symmetric torus using IDA since no single diagnostic can provide a robust measurement. As we enter the burning plasma era, application of IDA will be critical to the measurement of certain parameters, as diagnostic access in the harsh fusion environment will be extremely limited.