Proof-Grounded Patient-Specific Clinical Explanations from Knowledge-Graph Reasoning

Most clinical prediction systems learn patient-variable-outcome associations; we investigate a training-free diagnostic paradigm mapping patient observations to explicit medical knowledge. CKG Reasoner integrates candidate-specific Evidence Feature Nodes, patient-reference matching, a bounded Information Gate, knowledge-weighted evidence accumulation, disease similarity, and decisive clinical rules. Missing-aware normalization and coverage auditing distinguish absent from unavailable evidence. Candidate ranking is separate from outcome-label-independent K-means clustering, which uses four derived evidence coordinates (evidence strength, relative magnitude, directional similarity, and evidence completeness), not raw predictors or targets, to derive cohort-level assignments. Across six retrospective cohorts - four dengue (N = 1000, 1523, 989, 1018), malaria (N = 2190), and influenza (N = 4569) - a uniform, label-free, cohort-fitted K = 2 protocol yielded positive-class F1 scores of 0.996, 0.634, 0.936, 0.917, 0.695, and 0.842, and all-record accuracies of 0.996, 0.558, 0.914, 0.893, 0.707, and 0.906, respectively, with full partition-decision coverage using the frozen package and disease-specific knowledge representations. Neither scoring nor clustering uses outcome labels. Logistic regression provides a supervised baseline. Influenza incorporates confirmatory molecular PCR and is not independent pre-test prediction. Results characterize knowledge-grounded evidence separation, auditability, and sensitivity, not prospective clinical validity or comparative superiority. FOL/LLM-based clinical explanation remains unevaluated.

Reasoning benchmarks measure clinical performance on clean inputs. We evaluate the step before reasoning: retrieval over real EHR notes, where negation, temporality, and family-versus-patient attribution can flip a correct answer to a wrong one. EpiKG carries an assertion label and a temporality tag with every fact in a patient knowledge graph, then routes retrieval by question intent. ClinicalBench is a 400-question test over 43 MIMIC-IV patients across 9 assertion-sensitive categories. A 7-condition ablation tests each piece of EpiKG across six LLMs (Claude Opus 4.6, GPT-OSS 20B, MedGemma 27B, Gemma 4 31B, MedGemma 1.5 4B, Qwen 3.5 35B). Three physicians blindly adjudicated 100 paired items. The author-blind primary endpoint, leave-author-out paired exact McNemar on 50 unanimous-strict items rated by two external physicians, yields +22.0 percentage points (95 percent Newcombe CI [+5.1, +31.5], p=0.0192). The architectural novelty, intent-aware KG-RAG over a Contriever dense-RAG baseline (C2b to C4g_kw on the change-excluded n=362 endpoint), is +8.84 percentage points (paired McNemar p=1.79e-3); +12.43 percentage points under oracle intent. Sensitivities agree directionally: three-rater physician majority +24.0 percentage points (subject to single-author circularity); deterministic keyword reproducibility proxy +39.5 percentage points. Across the six models, the gain shrinks as the LLM-alone baseline rises (beta=-1.123, r=-0.921, p=0.009). With n=6 this looks more like regression to the mean than encoding substituting for model size. Physician adjudication identified 56 percent of auto-generated reference answers as defective, a methodological finding indicating that NLP-pipeline clinical-QA benchmarks require physician adjudication to be usable. ClinicalBench, the frozen evaluator, three-rater adjudication data, and the EpiKG output stack are publicly released.

Knowledge graphs (KGs) are increasingly used to support large lan guage model (LLM) reasoning, but standard triplet-based KGs treat each relation as globally valid. In many settings, whether a relation should count as evidence depends on the context. We therefore formulate triplet validity as a triplet-specific function of context and refer to this formulation as a Quantum Knowledge Graph (QKG). We instantiate QKG in medicine using a diabetes-centered PrimeKG subgraph, whose 68,651 context-sensitive relations are further annotated with patient-group-specific constraints. We evaluate it in a reasoner--validator pipeline for medical question answering on a KG-grounded subset of MedReason containing 2,788 questions. With Haiku-4.5 as both the Reasoner and the Validator, KG-backed validation significantly improves over a no-validator baseline ($+0.61$ pp), and QKG with context matching yields the largest gain, outperforming both KG validation without context matching ($+0.79$ pp) and the no-validator baseline ($+1.40$ pp; paired McNemar, all $p<0.05$). Under a stronger validator (Qwen-3.6-Plus), the raw QKG gain over the no-validator baseline grows from $+1.40$ pp to $+5.96$ pp; the context-matching gap is non-significant ($p=0.73$) on the raw set but becomes borderline significant ($p=0.05$) after adjustment for knowledge leakage and suspicious questions, consistent with a benchmark-gold ceiling rather than a QKG limitation. Taken together, the results support the view that the value of a KG in LLM-based clinical reasoning lies not merely in storing medically related facts, but in representing whether those facts are applicable to the specific patient context. For reproducibility and further research, we release the curated QKG datasets and source code.\footnote{https://github.com/HKAI-Sci/QKG}