Smartphone skin photographs are indispensable to teledermatology, yet assessing the diagnostic suitability of submitted cases (gradability) remains a critical bottleneck in mobile care workflows. Dermatologists routinely review multiple photographic views (regional, angled, and close-up) to identify consistent textural detail rather than relying on a single image. We present the Semantic Tri-view Pipeline, an interpretable architecture for automated teledermatology gradability screening that formalizes epidermal micro-relief as a computable biomarker of image quality. Using an expert-annotated subset of the public SCIN dataset, we train a lightweight DeepLabV3+ model to segment micro-relief fidelity. These spatial masks are then aggregated across up to three case views with a logistic regression classifier, leveraging viewpoint redundancy to support robustness under uncontrolled smartphone acquisition. This approach learns context-aware, clinically intelligible heuristics, such as penalizing high-fidelity texture in regional distance views. Evaluated at a predefined 90% sensitivity operating point, the system's apparent errors largely reflect subjective clinical variance on borderline cases where clinicians rely on non-visual metadata. On SCIN, performance improves from an AUC of 0.81 (80.6% PPV) on variance-heavy majority-consensus cases to 0.96 (97.7% PPV) on optically unambiguous unanimous cases. Overall, this work delivers an interpretable, privacy-by-design, edge-ready system that can provide real-time feedback during case submission to filter ungradable photo sets before review.
Ontology rankers remain useful for rare-disease diagnosis because each candidate can be traced to matched patient phenotypes. Large language models (LLMs) can generate differential diagnoses from the same patient description, but their predictions lack an equally clear evidence trail. Rather than asking which system should replace the other, we ask whether an LLM can improve the ranker without giving up its evidence. Our behavior-based fusion model examines the two ranked lists, their agreement, and the ontology support behind each candidate, and learns how much to rely on each system for the individual case. Before comparison, we remove a documented test-set leakage pathway caused by benchmark cases and ontology annotations being derived from the same publications. Across eight open LLMs, fusion improves Phenomizer Recall@1 by 7.86 percentage points on Phenopacket Store and 20.18 points on RAMEDIS. When paired with DeepSeek-V4-Flash through an API, a fusion model trained only on the other LLMs improves Recall@1 from 0.1657 to 0.2176, a 5.19-point gain, without retraining. For 90.8% of correct fused diagnoses, the disease retains candidate-level ontology evidence that can be inspected. These results show that LLMs can strengthen an established diagnostic tool without discarding the structured evidence that makes it useful.
Large language models (LLMs) offer promising clinical decision support but remain vulnerable to hallucinated facts, unsupported recommendations, and citation errors. We present DIASENTINEL, a fully on-premise multi-agent system for one-year type 2 diabetes mellitus (T2DM) risk screening and guideline-grounded report generation from electronic health records (EHRs). The system integrates calibrated risk prediction, deterministic clinical signal extraction, Reciprocal Rank Fusion over American Diabetes Association (ADA) guidelines, and a hybrid verification layer combining rule-based checks with LLM entailment. The demonstration provides a real-time batch-screening dashboard and an interactive patient report interface with cited recommendations, verification results, and raw EHR comparison. DIASENTINEL demonstrates a practical framework for reliable, auditable, and privacy-preserving LLM-based clinical decision support.
Ziheng "Leo" Li, Benjamin Freeman, Akshay Raman +5cs.AI cs.HC
Clinical AI often optimizes predictive performance without engaging how clinicians decide where to look and what to write. We present Co-Annotator, which distills expert gaze and dictation into two guidance components: a gaze-aligned Vision Transformer producing fixation-aligned areas of interest (AOIs), and an ontology-bounded vision-language model (VLM) that pre-fills editable biomarker summaries for retinal optical coherence tomography (OCT). We first collect expert gaze and dictations (US1) to train the models, significantly improving diagnostic accuracy and biomarker generation. We then deploy the system with ophthalmology residents: a controlled resident study (US2) confirmed each modality is safe and independently beneficial, with AOI guidance producing lasting perceptual efficiency gains through post-guidance carryover and VLM guidance more than doubling biomarker documentation breadth. In a combined deployment across two academic institutions (US3), providing both modalities simultaneously produced efficiency gains that substantially exceeded either modality alone: correct diagnoses per minute increased by 40% and comment editing time fell by 67%, without compromising diagnostic accuracy. Notably, neither modality improved efficiency during guidance in US2, which makes the in-guidance efficiency gain under combined guidance in US3 the more striking result. Expert-distilled multimodal guidance can remove two distinct clinical workflow bottlenecks at once (visual search overhead and documentation burden) without compromising the diagnostic accuracy clinicians already achieve.
Predicting future organ dysfunction in Intensive Care Unit (ICU) patients is critical for early clinical intervention, yet existing machine learning approaches have largely treated the Sequential Organ Failure Assessment (SOFA) score as an input to binary mortality prediction rather than as a continuous clinical outcome in its own right. We investigate the extent to which a Temporal Convolutional Net work (TCN) can predict next-day SOFA scores from multivariate ICU time-series data extracted from MIMIC-IV, characterise the relative contribution of each organ system to total SOFA variance and deterioration, and identify distinct trajectory patterns across ICU stays. A residual TCN trained on three-day sliding windows achieved a five-fold cross-validation R2 of 0.740 +- 0.013 and MAE of 1.431 +- 0.022, outperforming a naive persistence baseline on RMSE and R2. SHAP interpretability analysis revealed that the model functions primarily as a severity-anchoring mechanism rather than a true sequence model, with predictions dominated almost entirely by the most recent observation day. Cardiovascular dysfunction emerged as the strongest discriminator of both cross-sectional severity and acute deterioration, and unsupervised trajectory clustering identified two clinically meaningful phenotypes, an improving group (58.9%) and a persistently severe group (41.1%), differentiated by cardiovascular, hepatic, coagulation, and renal involvement. We conclude that TCNs can extract meaningful predictive signal from ICU physiological data, but that short input windows and complete-case selection bias currently limit their clinical utility, motivating future work on longer input horizons, alternative missing-data strategies, and external validation.
Li Rong Wang, Jamie Duell, Xinran Xu +6cs.LG cs.AI
Artificial intelligence has strong potential to support clinical decision-making, yet its adoption in healthcare remains limited due to a lack of trust. Uncertainty estimation can signal unreliable predictions, and explainable AI (XAI) can clarify how predictions are made but existing methods treat them separately, providing no feature-level insight into why a prediction is uncertain or which tests to prioritize to reduce it. To address this gap, we propose explainable uncertainty estimation, which unifies uncertainty estimation and XAI to both quantify uncertainty and explain feature-level contributions. We introduce the Expected Gradients Reconstruction Uncertainty Estimate (egRUE), which incorporates prediction explanations into its uncertainty computation and decomposes uncertainty into feature-wise contributions. We prove theoretical properties of egRUE and show through experiments that it improves reliability and interpretability compared to existing methods. A user study with medical experts further demonstrates that egRUE's explanations improve calibrated trust over uncertainty scores alone, increasing confidence in correct predictions and reducing confidence in incorrect ones. By combining prediction uncertainty with feature-level explanations, egRUE strengthens decision-making support in safety-critical healthcare settings, clarifying both when predictions may be unreliable and which features drive that uncertainty.
Currently used sepsis severity indices rely on fixed variables and weights established decades ago, which are coarsely discretized and calibrated to a cohort that no longer reflects contemporary critical care. No alternative learned directly from patient trajectories is in routine use. We conducted a retrospective two-cohort study on a total of 29,116 and 7,691 adult patients meeting Sepsis-3 criteria from two hospital systems in Massachusetts and Georgie, respectively. We developed a sepsis index using 43 routinely charted variables over a 72-hour treatment window. Unlike previous studies, we use mortality as a treatment-level ranking signal rather than a per-state target, allowing credit to be redistributed non-uniformly across timesteps. Evaluation was done on a permanent 20% test holdout, using clinical vignettes and Spearman correlation. Uncertainty intervals were obtained by bootstrap resampling of whole patients. Under this ranking scheme, non-survivors scored 1.19-1.64 points higher than survivors on a 0-10 scale within all strata of baseline SOFA-2, with similar results stratifying within lactate, mean arterial pressure (MAP), and creatinine. Within-patient change in the index correlated with change in lactate (Spearman rho = 0.39; n = 1,854). Similar, weaker correlations were found for MAP and creatinine. On a cohort level, cross-institutional agreement measured by Spearman correlation between models trained on different sites, were 70-77% of same-site correlation. External within-patient correlations were 0.54 and 0.59 against ceilings of 0.92 and 0.90. Our index also correlated with established indices, while null controls stayed near zero. Our index demonstrated hourly prognostic information that meaningfully separates patient outcomes and is consistent with clinical expectation, indicating potential as a decision support tool complementing clinical judgement.
Adverse drug reactions (ADRs) are a major, largely preventable source of patient harm. In high-income settings, electronic health records store a patient's allergy history and warn prescribers when a contraindicated drug is ordered; in rural Bangladeshi public hospitals no such record exists for outgoing patients, a single physician may see on the order of one patient per minute, and a patient's history of severe reactions does not survive between visits. This paper proposes and outlines the evaluation of a lightweight, smartphone-based safety-check system for this setting. At registration a soft identifier (a phone number) is recorded; after the physician writes a prescription, its image is captured, the brand names are resolved to active ingredients using national drug references, and the ingredients are matched against the patient's recorded severe reaction history. The system is retrieval-based rather than predictive, and is silent by default, raising a flag only for high-risk matches a design grounded in the alert-fatigue literature. We frame the work as a feasibility study: we describe the proposed framework and an evaluation plan measuring workflow fit under high volume, usability, identity-resolution reliability, and retrospective detection of known reaction cases. We explicitly do not claim a clinical-outcome effect, which the low base rate of severe events places beyond a single-site feasibility study.
Background: Automating clinical guideline-based decision-making with large language models (LLMs) remains challenging because of reliability, hallucination, and limited interpretability. We compared the performance of LLMs and reasoning strategies for automated Ovarian-Adnexal Reporting and Data System (O-RADS) classification from free-text pelvic ultrasound reports. Methods: In this retrospective study, consecutive patients with ovarian masses who underwent pelvic ultrasound were included. Eight LLMs were tested with three reasoning strategies: implicit-knowledge end-to-end, rule-informed end-to-end, and a feature-based hybrid architecture that decoupled feature extraction from rule-based classification. The reference standard was O-RADS categorization established by expert consensus. Results: A total of 310 women with 390 ovarian masses were evaluated. The feature-based hybrid architecture using Gemini 3.6 Flash demonstrated the best performance, achieving an accuracy of 99.2% (387 of 390) and almost perfect agreement with the reference standard (weighted kappa = 1.00; 95% CI: 0.99-1.00). Its performance surpassed that of original clinical reports (accuracy, 87.7% [342 of 390]; weighted kappa = 0.94; 95% CI: 0.91-0.96) and end-to-end LLM strategies (accuracy range, 65.6% [256 of 390] to 95.9% [374 of 390]). For structured feature extraction, Gemini 3.6 Flash demonstrated higher overall accuracy than Claude Fable 5 (98.9% vs 97.8%; P < 0.001). The hybrid architecture reduced misclassification errors and mitigated the overstaging tendency observed in original reports. Conclusion: The feature-based hybrid LLM architecture that separates clinical feature extraction from deterministic guideline execution enables highly accurate, reliable, and interpretable automated O-RADS classification, providing a promising approach for standardized, guideline-based clinical decision-making.
Unlike static medical question answering, long-horizon diagnosis captures the sequential nature of clinical practice: evidence is progressively acquired, integrated, and evaluated over multiple rounds of interaction before reaching a final diagnosis. However, existing doctor agents often fail when critical evidence is either not acquired or not adequately incorporated into diagnostic reasoning. Recent agentic approaches attempt to address these failures by reusing historical trajectories or distilled memories. But their diagnostic gains remain constrained because such experience may contain noisy or incidental information and is typically reused without validating which evidence actually drives diagnostic decisions. To address this limitation, we introduce CDEG, a graph-based framework that learns reusable decision-critical evidence from historical diagnostic trajectories. CDEG contrasts successful and failed trajectories from the same case to identify candidate evidence, validates their diagnostic impact through controlled counterfactual interventions, and organizes the resulting diagnosis--evidence--action relations into a structured graph. During inference, CDEG tracks the evolving patient evidence state to retrieve relevant diagnostic relations and selectively guide missing evidence acquisition or overlooked evidence reappraisal. Across in-domain and out-of-distribution benchmarks with multiple doctor agent backbones, CDEG consistently improves diagnostic performance, achieving up to an 11.5% accuracy gain over vanilla agents. These results demonstrate that reliable long-horizon diagnosis requires moving beyond trajectory-level experience reuse toward evidence-level learning of the factors that truly shape clinical decisions.
Medical large language models are often judged by how many clinical questions they answer correctly. That view is useful, but it misses a practical risk. A model may know the right answer and still change its response when the same case is written in a different patient voice. This paper evaluates that risk as SDoH aware narrative anchoring bias. We use NarrativeShield SDoH MedQA, a counterfactual medical question answering dataset in which each case appears in persona based narratives while the answer key remains fixed. The dataset is reshaped from wide format into case grouped persona rows. We evaluate three open source instruction tuned LLMs from the Qwen2.5 family: 1.5B, 3B, and 7B. The final experiment uses 300 clinical cases and produces 8,100 model responses across three prompting conditions. We report persona level accuracy, counterfactual consistency, correct consistency, and narrative sensitivity error. Qwen2.5 7B achieves the best accuracy at 56.33 percent and the best correct consistency at 40.33 percent. Paired McNemar exact tests show significant accuracy gains for 7B over 3B in all prompt settings. Even so, narrative sensitivity remains, with the lowest error still at 31.67 percent. These results suggest that trustworthy clinical decision support should be evaluated by both average correctness and stability across medically equivalent patient narratives.
Incident risk prediction from longitudinal electronic health records (EHRs) is challenging because relevant signals are multimodal, weak in isolation, and distributed across irregular patient histories. We propose structured evidence routing, a router-predictor-reviewer workflow that separates full-record access from disease-specific assessment. The router organizes the complete pre-index EHR into a compact summary and targeted evidence slices; the predictor uses this evidence to form an evidence-linked risk assessment, which the reviewer critiques. For comparison with supervised EHRSHOT baselines, we pair the routed evidence summaries with a supervised classifier readout. Across five 1-year incident diagnosis tasks, our method reaches the AUROC range of established supervised EHRSHOT baselines and remains competitive on AUPRC, while exposing a patient-specific evidence trail. Internal pre-readout ablations further suggest that routing, laboratory evidence, task guidance, and review each contribute to performance.
The application of Large Language Models (LLMs) to diagnostic decision-making has garnered growing interest. However, existing benchmarks largely focus on textual reasoning or isolated visual question-answering (VQA) tasks, lacking holistic integration of clinical narratives and medical imaging, and thus failing to assess the multimodal diagnostic synthesis capability central to expert clinical judgment. To bridge this gap, we introduce MedReaMM, a benchmark specifically designed to evaluate models' ability to synthesize heterogeneous clinical evidence consisting of detailed patient histories alongside multiple medical images into accurate differential diagnoses under a complete-information paradigm. Constructed from case reports sourced from top-tier medical journals and curated clinical case databases, MedReaMM comprises 625 expert-validated cases with an average of 2.79 medical images per case and a total of 1,042 standardized diagnoses annotated with ICD-11 codes. These cases predominantly represent rare, atypical, or multi-system presentations that demand expert-level evidence integration beyond routine pattern recognition. We evaluate 23 Large Multimodal Models (LMMs) and find that most achieve diagnostic accuracy scores below 50%, underscoring a substantial gap in multimodal diagnostic synthesis capability. Further analysis reveals that medical knowledge proficiency, medical image understanding, and evidence integration are all highly correlated with diagnostic performance.
Dawa Chyophel Lepcha, Aaliya Ali, Sophie A. Martin +3eess.IV cs.AI cs.CV cs.LG
Multimodal neuroimaging combining structural MRI and positron emission tomography (PET) captures complementary structure-function relationships across the Alzheimer's disease (AD) continuum, yet existing artificial intelligence systems produce a single diagnostic label without quantifying which imaging modality drove that decision for a specific patient. We introduce the Modality Contribution Network (MCNet) and the Modality Contribution Score (MCS), the first per-patient attribution framework quantifying the shift in modality dominance from structural atrophy to amyloid and metabolic dysfunction across the cognitively normal to MCI to AD continuum. MCS is normalised to unity per subject via modality ablation (MCS_MRI_i + MCS_PET_i = 1.0 for every subject i), providing an interpretable, clinically actionable score that fluid biomarkers cannot supply. Applied to 327 ADNI-3 participants balanced across cognitively normal, mild cognitive impairment, and AD groups, MCNet achieved competitive three-class staging performance (AUC=0.881). The MCS revealed a statistically significant monotonic gradient (Kruskal-Wallis p<0.0001), with increasing PET dominance from cognitively normal (MCS_PET 0.412+/-0.229) through MCI (0.489+/-0.289) to AD (0.671+/-0.426), validated against amyloid SUVR (r=0.172, p=0.006) and FDG metabolic biomarkers (r=-0.287, p=0.0005) from separate imaging pipelines. External replication in 1,073 independent OASIS-3 subjects confirmed cross-cohort generalisability (H=166.99, p<0.0001, eta^2=0.156). A mechanistic comparison with SHAP demonstrated that ablation-based MCS captures clinically meaningful modality dependence that deviation-based methods cannot. These findings position MCNet as a foundation for personalised imaging decisions, clinical trial stratification, and trustworthy AI in dementia care.
Breast Cancer Multidisciplinary Team (MDT) meetings manage increasingly complex cases under considerable time pressure, and documentation requirements can reduce clinical efficiency and decision quality. Existing AI based MDT workflows rely on cloud-based processing, limiting their use because patient discussions contain identifiable information. We developed a fully on-device AI pipeline using open-source Automatic Speech Recognition (ASR) and Large Language Models (LLMs) that transcribes breast cancer MDT discussions, structures clinical information, and generates treatment recommendations using retrieval-augmented generation (RAG) grounded in National Institute for Health and Care Excellence (NICE) guidance. The pipeline runs on a single NVIDIA Jetson AGX Orin, ensuring that patient audio, transcripts, and outputs remain within institutional infrastructure. Evaluation included two recorded simulated MDT discussions, ten clinically validated synthetic discussions, and 1,270 acoustically augmented recordings. Optimisation of Whisper large-v3 reduced word error rate by 20.7% and 24.4% on the recorded discussions and achieved performance within 0.58% WER and 1.58% word information lost of a commercial clinical ASR benchmark on augmented audio. MedGemma-RAG identified 2.3 times more MDT-concordant interventions than a proprietary cloud comparator (p = 0.020), with no significant difference in overall accuracy. Stakeholders identified automated documentation, treatment recommendation support, and case triage as the most credible near-term applications while highlighting workflow integration, governance, and clinician trust as key implementation challenges. These findings demonstrate the feasibility of privacy-preserving, fully on-device AI for MDT documentation and guideline-informed decision support, providing a foundation for prospective clinical evaluation.
Bipasha Kundu, Abhishek Chaturvedi, Axel W. E. Wismueller +2eess.IV cs.CV
LGE cardiac MRI is widely used for left atrial fibrosis assessment and ablation planning in atrial fibrillation patients as knowledge of fibrotic tissue regions identified from LGE-MRI is critical for catheter ablation. Often, poor quality images used during ablation planning can cause mis-localization of ablation targets, directly impacting procedure safety and outcome. The decision of whether a scan meets the minimum quality threshold for ablation planning is currently made informally by the reviewing radiologist and is not captured by any automated system, yet it is arguably the most safety-critical output of the image quality assessment (IQA) process. However, variations in image quality caused by noise, motion artifacts, and poor boundary definition significantly compromise the reliability of downstream segmentation and clinical decision-making tasks. Manual quality assessment by expert radiologists is subjective and difficult to scale, while existing automated methods produce scalar scores without interpretable clinical reasoning. In this work, we propose a two-stage vision language model (VLM) framework for clinically grounded image quality assessment of left atrial LGE-MRI. In the first stage, a fine-tuned VLM generates structured radiology-style quality reports predicting five radiologist-defined criteria: Noise, Motion Artifact, LA Boundary Accuracy, PV Region Accuracy, and Under-segmentation Severity. In the second stage, a GPT-based reasoning module maps the predicted quality and reports to a structured quality scores and binary clinical usability decision for ablation planning. We curate a dataset of 60 annotated image slice-text pairs from 20 patients and benchmark four state-of-the-art VLM architectures. InternVL2 achieves the highest criterion-level accuracy (Avg ACC=0.65, PLCC=0.79), while DeepSeek achieves perfect clinical usability agreement (Acc=1.00, kappa=1.00).
Yunxiang Li, Yan Dai, Yen-Peng Liao +3physics.med-ph cs.AI
Background: Magnetic resonance imaging-guided linear accelerators (MR-Linacs) allow diffusion-weighted imaging (DWI) to be acquired at every treatment fraction, but converting these low-signal-to-noise-ratio acquisitions into clinical decisions requires both reliable quantitative processing and an interpretation that reconciles a scattered and often contradictory literature. Purpose: To describe and evaluate an integrated, web-based platform that carries raw MR-Linac DWI to a structured, literature-grounded clinical interpretation, and to assess its retrieval-augmented generation (RAG) interpretation module by independent expert rating. Methods: The platform couples a deep-learning processing pipeline, comprising distortion correction, denoising, and intravoxel incoherent motion (IVIM)/apparent diffusion coefficient (ADC) fitting, with longitudinal region-of-interest analysis and a RAG interpretation agent. The agent reasons over a two-layer knowledge base of curated publications (a structured catalog index plus line-indexed full text), delegates arithmetic to deterministic tools, and is designed to trace each statement to a source document, section, and line range. One medical physicist and one physician independently rated the agent's reports for nine longitudinal glioblastoma cases on a 1-5 scale across three metrics: clinical-reasoning soundness, literature-citation quality, and overall clinical utility. Results: Across 54 ratings, the pooled mean was 4.65 +/- 0.80, with 93% of ratings >= 4; metric means were 4.6 (reasoning), 4.5 (citation), and 4.8 (utility), and raters agreed within one point on 85% of paired ratings. Conclusions: A single platform can integrate MR-Linac DWI post-processing with traceable, expert-evaluated clinical interpretation, while highlighting the safeguards needed to verify LLM-generated reasoning in radiation oncology.
Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) can worsen rapidly, making timely prediction a clinical priority. Most existing machine learning approaches rely on episodically collected clinical variables, introducing delays that limit their practical utility in home monitoring settings. Home ventilators offer a lower-latency alternative, producing a near-continuous record of respiratory status during daily use. However existing ventilator-based approaches either compress the waveform into handcrafted features or focus primarily on binary risk classification, leaving the timing of an impending event unresolved. In this paper, we present a two-stage framework that operates directly on raw pressure and flow waveforms from the most recent seven days of home ventilator use. The first-stage classification model identifies patients at high risk of a severe exacerbation. The second-stage regression model then estimates how many days remain before the event occurs. Our experimental results demonstrate that the two-stage model outperforms traditional baseline models on both risk classification and time-to-event estimation, with our selected Stage 1 classifier achieving F1 = 0.91 and our Stage 2 regression model achieving RMSE = 1.00 days and R^2 = 0.76, giving clinicians both an early warning and actionable lead time before a severe exacerbation occurs.
Heart disease remains the leading cause of mortality globally, necessitating early and accurate detection to improve patient outcomes. This research focuses on the predictive analysis of heart disease using machine learning (ML) techniques, comparing the performance of multiple classifiers to identify the most accurate and least error-prone method. Two datasets from UCI and Kaggle repositories were utilized, each containing 14 attributes related to heart health indicators. Techniques including J48, Naive Bayes, Logistic Regression, Simple Cart, Bagging, Decision Stump, AdaBoost, Artificial Neural Networks, and Support Vector Machine (SVM) were applied. Evaluation metrics such as Mean Absolute Error (MAE), Relative Absolute Error (RAE), accuracy, precision, recall, and F-measure were used for performance comparison. Results revealed that SVM achieved the highest performance on the UCI dataset, while Simple Cart performed best on the Kaggle dataset, offering the highest accuracy and lowest error rates. The research work concludes that ML models, when properly tuned and validated, can significantly assist in the early diagnosis of heart disease, offering critical support for clinical decision-making. Future work may involve hybrid approaches and the use of more recent datasets to further improve prediction accuracy.
Marc Pérez-Roig, David Fernández-Narro, Carlos Sáezcs.AI cs.LG
The dosing of intravenous fluids and vasopressors in sepsis is a sequential decision made under uncertainty and guided largely by clinical judgment, which makes it a natural target for reinforcement learning from historical care. Because a learned policy cannot be trialed on patients, its value must be estimated off-policy, and such estimates can be fragile and optimistic. This work advances the reliable evaluation of sepsis treatment policies by combining off-policy estimation, reliability diagnostics, and clinician-agreement analyses in a transparent validation framework. We modeled fluid and vasopressor dosing on a cohort of 36,872 septic ICU stays drawn from the MIMIC-IV critical-care database, as a discretized Markov decision process with 1,000 states and 25 actions, defined by a five-by-five grid of fluid and vasopressor levels and solved by policy iteration. The clinicians' behavior policy was estimated with a random forest, which mitigated the collapse of the Effective Sample Size (ESS 50.1 against 4.0 with smoothed counts) that otherwise destabilizes the importance-sampling estimate. The learned policy was evaluated with two estimators, weighted importance sampling (WIS) and fitted Q evaluation (FQE), with the ESS and clinician agreement as reliability checks. An empirical variable selection found that the composition of the state matters more than its size. Both estimators place the learned policy above the clinicians' return (WIS 50.8 and FQE 46.8 against 38.2, ESS 50.1), yet it departs only modestly from observed practice (total variation 0.18), favoring less intravenous fluid. These retrospective single-center off-policy results support the learned policy as a clinically plausible refinement of observed practice and motivate its further evaluation as a discordance-based clinical decision-support approach.
Rakesh Sharma, Sydney Pugh, Cameron Beeche +14cs.MA cs.AI cs.LG
The rapid adoption of large language models has enabled the development of clinical multi-agent systems (MAS) capable of integrating multimodal patient data and supporting increasingly complex clinical decision-making. However, the deployment of these systems in real-world healthcare settings raises critical ethical concerns related to safety, fairness, accountability, transparency, and patient trust. While numerous organizations, including the World Health Organization, the National Academy of Medicine, and the FUTURE-AI consortium, have proposed ethical frameworks and governance principles for healthcare AI, these efforts remain largely conceptual. To address this challenge, we present ETHOS (Ethics and Trust through Hierarchical Oversight System), a modular ethics framework designed as a governance meta-agent that can be integrated with any existing multi-agent system without requiring changes to its underlying architecture. ETHOS translates stakeholder-informed ethical requirements into executable runtime oversight through a layered governance approach consisting of deterministic checks, contextual reviews, and a final ethics critic. These components continuously evaluate intermediate reasoning steps and final outputs, enabling the system to identify ethical risks, request revisions, or suppress responses that fail predefined safety and trustworthiness criteria. We demonstrate ETHOS within a hepatology clinical decision-support MAS. Results show that ETHOS improves decision reliability by detecting incomplete, inconsistent, or out-of-scope evidence and appropriately increasing abstention when safe recommendations cannot be supported. By embedding ethical governance directly into system operation, ETHOS provides a practical and auditable mechanism for transforming high-level AI ethics principles into deployable safeguards.
Lung cancer remains one of the leading causes of cancer-related mortality worldwide, and Computed Tomography (CT) is a primary imaging tool for screening and followup assessment. After pulmonary nodule detection, radiologists manually assess anatomical location, diameter, margin characteristics, and attenuation type to support risk assessment and clinical decision-making. However, this post-detection workflow is time-consuming and can be affected by inter-observer variability. Existing Artificial Intelligence methods often focus on isolated tasks, limiting their use as a unified, clinically grounded interpretation framework. This study presents FZ-VLM, a two-stage Florence-Zephyr Vision Language Model framework for unified structured pulmonary nodule characterization in lung CT. The framework uses a fine-tuned Florence-2 model to extract radiological attributes from expert-annotated 2D axial CT slices, while a Zephyr-7B model uses these attributes to generate nodule descriptions, follow-up recommendations, and longitudinal analyses. Results showed that the Stage 1 model achieved 77.18\% accuracy for anatomical location, 67.96\% accuracy for margin characteristics, and 79.13\% accuracy for attenuation type, with a Mean Absolute Error of 2.58 mm for diameter estimation, outperforming evaluated GPT-4-based baselines as well as the human baseline. Expert radiologist evaluation of Stage 2 showed 93.9\% accuracy, 98.6\% completeness score, 76.1\% clinical relevance, and an overall score of 89.5\%. Safety analysis showed that most outputs were clinically safe, although some follow-up recommendations still required expert review. To the best of our knowledge, this study presents the first two-stage Vision-Language Model framework for structured nodule characterization and clinical decision-making.
Mechanical ventilation is a critical life-support intervention, requiring dynamic adjustments to ventilator settings as a patient's condition evolves. While reinforcement learning (RL) offers a promising framework for optimizing these sequential decisions, standard approaches rely primarily on structured electronic health record (EHR) data, missing crucial clinical context recorded in free-text notes. Integrating longitudinal clinical notes into RL state spaces is challenging because notes are heavily inflated by temporal redundancy, such as copy-forward text, templating, and repetitive documentation, which dilutes time-local updates and degrades state representation quality. To address this, we propose a redundancy-aware multimodal state representation framework that explicitly removes duplicated note text over time before policy learning. We evaluate two computationally efficient temporal decomposition strategies for removing duplicated note text: (1) an embedding-space decomposition using singular value decomposition on local history subspaces, and (2) an interpretable sentence-level diff operation that filters out previously documented sentences before text encoding. Using real-world ICU data, we demonstrate that state representations constructed by stripping temporal note redundancy significantly outperform both structured-only and raw-note baselines across multiple off-policy evaluation methods (Model-Based Rollouts, Fitted Q-Evaluation, Weighted Importance Sampling, and Weighted Doubly Robust Evaluation). Our findings show that explicitly isolating new clinical information from repeated note text yields higher-quality state representations and directly improves RL performance for clinical decision support.
Haifan Gong, Shiyu Chen, Bodong Wang +11cs.AI cs.CV
Thyroid ultrasound diagnosis requires coordinated lesion localization, measurement, risk stratification and reporting, yet most AI systems address these tasks in isolation and provide limited support for clinical review. We present ThyroidXAgent, a clinician-interactive agentic AI system that coordinates specialized diagnostic tools and stores their outputs as an auditable case-level evidence record. The system was developed using OpenThyroidDB, a multicentre, multitask resource integrating approximately 0.3 million ultrasound images and 24,000 paired reports, and was evaluated on 28,458 non-overlapping test cases, including 8,721 cases from 35 centres in the private NHC-MISD-TUS cohort. Across heterogeneous datasets, ThyroidXAgent achieved a mean Dice score of 87.21 percent for nodule segmentation and a mean AUROC of 0.9466 for benign-malignant classification. The same workflow supported lymph-node metastasis prediction and follicular versus papillary thyroid carcinoma classification, with AUROCs of 0.864 and 0.805, respectively. For report generation, evidence-grounded assembly outperformed multimodal language-model baselines across three cohorts. ThyClinScore, a lesion-level clinical semantic metric introduced here, showed the strongest correlation with a location-aware language-model judge. ThyroidXAgent improved physician classification accuracy, increased report diagnostic consistency from 70.3 percent to 86.2 percent, and reduced segmentation and reporting time by 35.9 percent and 27.4 percent, respectively. These findings support auditable, clinician-correctable agentic AI for thyroid ultrasound diagnosis and reporting.
Burcu Ozek, Aruna Mohan, David Vorchheimer +5cs.CV cs.LG
Reduced left ventricular ejection fraction (LVEF) is frequently asymptomatic and often detected only after advanced heart failure develops. Electrocardiograms are recorded routinely yet underused for this condition, because reduced LVEF has no single diagnostic waveform. We trained an ensemble of vision transformers from scratch to detect reduced LVEF ($\leq$40%) from 12-lead ECGs, analyzing each heartbeat individually, using 10,142 patients across seven sites in three US health systems. In a held-out external cohort of 4,092 patients from three geographically independent US clinical sites at a real-world reduced-LVEF prevalence of 8.72%, the model achieved an AUROC of 0.88 (95% CI 0.86-0.89), sensitivity 81.2%, specificity 81.0%, and negative predictive value 97.8%. Sensitivity remained high across sex, race, ethnicity, and comorbidity subgroups, while specificity was lower in older patients and those with atrial fibrillation or cardiomyopathy. Beat-level attention maps provided interpretability into the model's predictions, showing consistent focus on the QRS complex rather than the P wave. These findings support the potential of routine ECGs as a scalable first-pass triage step to identify patients who should undergo echocardiography for reduced ejection fraction across diverse patient populations.
Deploying large language models (LLMs) for decision support in emergency departments (EDs) faces two major challenges: privacy risks of transmitting patient data to closed-source commercial LLMs and the lack of systematic evaluation of fine-tuning strategies for locally deployable open-source small language models (SLMs). We benchmarked eight open-source SLMs using zero-shot prompting, prefix tuning, Low-Rank Adaptation (LoRA), and full fine-tuning on three ED tasks: triage level prediction, specialist referral recommendation, and diagnosis prediction. Using 2,083 MIMIC-IV-ED cases and Claude Haiku 4.5 and Claude Sonnet 4.5 as baselines, we found that LoRA fine-tuned open-source SLMs outperform commercial baselines on triage level prediction and specialist referral recommendation, while diagnosis prediction remains challenging for open-source SLMs. Confusion matrix analysis further shows that fine-tuned open-source SLMs can detect highest-severity patients missed by the commercial baselines. These results demonstrate that locally deployable SLMs can achieve clinically competitive performance for ED decision support.
Perioperative risk prediction models are often limited by narrow surgical populations, incomplete intraoperative data, poor calibration, and limited interpretability. We present a domain-structured ensemble framework for perioperative outcome prediction using routinely collected electronic health record (EHR) data. Predictors are organized into patient-related, surgery-related, and anesthetics-related domains. Domain-specific gradient boosting models generate independent risk estimates that are integrated through a logistic regression meta-learner. We demonstrate the framework using postoperative delirium (POD) in a case-control sample of 5,386 surgical encounters (2,693 cases, 2,693 controls) from a statewide health information exchange. POD required both delirium-related ICD codes and a positive Confusion Assessment Method screening within seven postoperative days; patients with preexisting dementia were excluded. The stacked meta-learner achieved AUROC 0.899 (95% CI: 0.891-0.906), precision-recall AUC 0.881, and Brier score 0.126, compared with AUROC 0.849 for the best single-stage model. Domain ablation showed improved discrimination and calibration over a surgery-only model (AUROC 0.879, Brier 0.140). Temporal validation on held-out post-2017 data yielded AUROC 0.915. Calibration was excellent, with intercept -0.006 (95% CI: -0.083 to 0.070) and slope 1.035 (95% CI: 0.982 to 1.088). Decision curve analysis, corrected for case-control sampling, showed positive net benefit across clinically plausible thresholds. The modular framework supports alternative outcomes, extension of predictor domains, and dynamic risk updating, providing a scalable foundation for interpretable, calibration-aware perioperative clinical decision support.
Estimating counterfactual outcomes over time from longitudinal observational data is central to clinical decision support. Existing methods rely on domain confusion -- adversarial training that renders representations invariant to treatment assignment -- yet this invariance creates a mutual information conflict: it suppresses treatment-correlated covariate signals necessary for accurate outcome prediction. We formalise this tension via a Jensen-Shannon divergence bound on counterfactual prediction error and develop two complementary models. CSSD (Causal State-Space model with Direct decoder) adapts selective State Space Models with a parallel multi-step decoder that eliminates accumulated rollout error by producing all prediction horizons simultaneously in a single forward pass. CSSPD (Causal State-Space model with Predictive regularisation and Direct decoder) augments CSSD with Contrastive Predictive Coding and Local Information Maximisation to reinforce temporal predictability in the balancing representation and recover local covariate information destroyed by domain confusion. On MIMIC-III, CSSPD achieves lower counterfactual RMSE than the Causal Transformer at every horizon tau >= 2 at O(T) encoder cost, with gains from 0.02 (2-step) to 0.07 (6-step). On Cancer Simulation across confounding strengths gamma in {0,1,2,3,4}, CSSPD outperforms CT at gamma <= 3 (margins 25.9%--37.0%), and CSSD achieves the lowest overall average RMSE (12.7% reduction over CT), confirming the MI conflict analysis. To our knowledge, this is the first work to formalise the balancing-prediction MI conflict and propose a structured resolution through complementary predictive and information-theoretic training objectives.
Machine learning models achieve strong predictive accuracy for 90-day outcome prediction in acute ischaemic stroke, yet clinical adoption is limited by the misalignment of model explanations with clinicians' reasoning. Motivated by a clinician user study calling for clinical guideline-aligned cut-offs, we ask whether continuous predictors can be replaced by clinically informed categorical encodings without sacrificing performance. On a multi-centre European registry stratified into three treatment cohorts, we compare standard and fully categorised gradient-boosted models, the latter using stroke guideline-aligned, treatment-specific thresholds. The fully categorised models are statistically indistinguishable from their continuous counterparts in two of the treatment cohorts, with a significant drop in predictive accuracy in one cohort. Global feature importance rankings remain consistent, suggesting that discretising continuous predictors into guideline-based categories preserves the core hierarchy of prognostic factors across all treatment groups. Guideline-based categorisation is thus a viable design choice for stroke-outcome models.
Emergency triage requires reliable decisions within a short time period. However, the available electronic health record (EHR) data, including structured data and clinical text, are often incomplete, unreliable, and inconsistent. This makes machine learning (ML)-based triage prediction more challenging, as existing ML models typically rely on complete and reliable EHR data to accurately predict patients' acuity levels. To address this, we propose confidence- and reliability-aware selective triage (CRS-Triage) to predict patients' acuity levels with a confidence score. By comparing the confidence score with a predefined threshold, CRS-Triage can selectively determine whether the model should make the decision or defer the case. Specifically, CRS-Triage separately evaluates the reliability of structured data and clinical text and then jointly considers the consistency between the two modalities to estimate the confidence of each prediction. Moreover, to reduce the risk of missing high-acuity patients, namely under-triage, CRS-Triage prefers to assign patients slightly higher acuity levels, namely over-triage, by penalizing under-triage errors. Experiments on the MIMIC-IV-ED dataset show that CRS-Triage achieves strong predictive performance. It also provides a better risk-coverage trade-off and remains reliable when the available EHR data are incomplete, degraded, or inconsistent across modalities.