Clinical AI in EHR

Neonatal respiratory diseases are a major cause of neonatal morbidity and mortality, posing substantial challenges in clinical practice. Despite recent advances, existing Multimodal Large Language Models (MLLMs) face two key limitations in neonatal diagnosis: (1) domain gap arising from predominantly adult training data; (2) insufficient integration of multidimensional clinical context for accurate diagnosis. To address these challenges, we collect two real-world clinical datasets (NeoCXR and NeoCXR-EV) and propose NeoRed, to the best of our knowledge, the first MLLM tailored for neonatal respiratory disease, filling the gap in neonatal diagnostic reports generation. To enhance joint diagnosis from heterogeneous clinical context and chest X-rays, we design a novel Knowledge-Logic-Alignment (KLA) framework which constrains model behavior from three perspectives: 1) Knowledge Prior Injection (KPI) incorporates neonatologist-inspired diagnostic priors into multimodal representations, guiding disease-specific attention across modalities; 2) Diagnostic Logic Constraint (DLC) aligns the semantics of generated reports with multimodal diagnostic logic; and 3) Visual Semantic Alignment (VSA) establishes semantic correspondence between visual features and imaging conclusions. Extensive experiments demonstrate that NeoRed enables accurate neonatal diagnostic reports generation, achieving ROUGE-L of 53.29% and Clinical Efficacy F1 score of 65.19% on NeoCXR, outperforming existing MLLMs. NeoRed also preserves competitive report generation performance on adult benchmarks (MIMIC-CXR and IU-Xray). Datasets will be available upon application.

Retrieval-augmented generation (RAG) can improve the specificity and grounding of large language model responses, but its effect is not uniformly beneficial in single-turn mental-health question answering, where user queries often combine emotional distress, treatment concerns, and safety-sensitive needs. We study when retrieval helps or hurts mental-health QA, and whether a lightweight selective retrieval policy can better control this trade-off. We operationalize retrieval need using three draft-conditioned utility dimensions: psychoeducational need, coping need, and response specificity, together with a rule-based safety trigger. Following psychotherapy-grounded RAG systems such as coTherapist, we construct a compact and controllable guideline corpus comprising coping-strategy, psychoeducational, and safety resources. We fine-tune an instruction-tuned generator on MentalChat16K using QLoRA and compare Closed-book, Always Retrieval, and Selective Retrieval settings on CounselBench-Eval and CounselBench-Adv. Experiments show that retrieval is not uniformly beneficial in this domain. Always Retrieval improves specificity but lowers overall quality and introduces additional safety-sensitive failures. Selective Retrieval preserves closed-book behavior for low-need cases while avoiding the additional degradation caused by unconditional retrieval, supporting the view that retrieval activation is a safety-sensitive control decision.

A benchmark score credits final answers, but not the route by which an item can be answered. In medical multimodal multiple-choice questions (MCQs), this distinction matters because a correct answer can be supported by the intended image finding or by benchmark-preserved cues in the wording of answers, non-visual clinical text, visible image text, artificial annotations, or device/context artifacts. We call the resulting score-level overinterpretation reasoning inflation. Here, a route is an observable input path that can support answer selection, not a claim about the model's hidden cognition. Across six medical multimodal MCQ datasets, we separate candidate cues from behavioral evidence through prompt- and image-side audits, modality ablations, and matched repairs that preserve the medical target and answer key. In a 13-configuration open-model panel, full-input accuracy is 62.63%, while text-only and options-only settings achieve 53.96% and 29.71%, respectively. Removing length-gap, absolute/conspicuous, and spatial/prepositional cues lowers accuracy by 6.58, 3.50, and 4.77 percentage points. We also construct MedQA-MM, a 1,000-item shortcut-mitigated subset, where text-only and options-only accuracy fall to 5.21% and 12.33%. This does not imply that models never use images; it shows that medical image-reasoning claims require route-level evidence.

Counterfactual audits are the standard tool for checking whether a clinical agent treats demographically distinct but clinically identical patients differently. They report a flip rate: how often an action changes when only the patient descriptor changes. We show that this quantity is uninterpretable on its own. Re-running an identical condition ten times over sixteen vignettes (same narrative, same descriptor string, nothing varied) moved a clinical agent's action in 8.7% of outcome-vignette cells, and instability was heterogeneous across actions by a factor of eight, from 0.022 for ICU escalation to 0.179 for controlled-substance caution. No demographic contrast in our data was distinguishable from that floor. A second model gives a pooled floor of 6.7% and ranks the six actions almost identically (Spearman 0.94, exact p=0.017), so the floor is not one system's artefact. Majority-vote aggregation over five draws removes 39% of it and then flattens, and a null simulation attributes the residue to heterogeneous per-cell rates, so replication mitigates without eliminating. Any counterfactual fairness estimate reported without a per-action floor beside it therefore cannot be read as evidence of disparity. The measurements were taken with FairMedAgent, an evaluation harness for disparity in the actions of clinical LLM agents whose estimand, the within-range counterfactual flip rate, counts only flips between actions a published decision rule admits and a clinician has adjudicated. That estimand requires band adjudication, which is under way; no disparity result is claimed here. Each synthetic vignette runs a six-stage trajectory (five model-facing decisions around a deterministic environment step) under fixed-form conditions spanning race, sex, age, insurance, English proficiency, and their intersections. The harness, the floor protocol, and every analysis script are released.

Clinical prediction can saturate for two different reasons: a fitted learner may fail to extract available information, or the recorded variables may impose a population frontier. We separate these quantities through the \emph{learner gap} and the \emph{measurement-channel ceiling}. Optimal balanced accuracy is characterized by total-variation separation, yielding architecture invariance, a sharp partial-identification result under replacement contamination, a cross-fitted ceiling estimator, and exact conditions for multimodal decision improvement. We add two finite-sample diagnostics, namely a label-permutation optimism floor and an underfit curve, and validate the audit on three real cohorts: UCI readmission ($n=99{,}343$), BRFSS diabetes ($n=253{,}680$), and NHANES HbA1c ($n=10{,}219$). Well-tuned gradient boosting nearly reaches the estimated frontier in UCI and BRFSS, whereas deliberately or practically deficient learners retain large gaps. NHANES yields a null difference between questionnaire and measured marginal frontiers but a significant joint complementarity gain, refining the simplistic claim that an objective modality must dominate. Across all cohorts, modest AUROC gains coexist with substantially larger Bayes decision-flip rates, and several architectures estimate similar frontiers while their achieved balanced accuracy differs sharply. A PRISMA-guided synthesis of 104 clinical tasks then shows that the same channel-level regularities recur across more than 18 disease categories: a broad but non-universal structured-clinical region, diminishing same-channel gains across model families, and higher performance when measurement channels change. The framework converts saturation from an empirical observation into an auditable decision: improve the learner when headroom remains; improve measurement when it does not.

Longitudinal prediction from electronic health records (EHRs) is limited by the sparsity and irregularity in patient trajectories, and knowledge augmentation with external knowledge graphs (KGs) offers a promising way to alleviate these issues. However, most existing methods perform fixed, context-agnostic topology augmentation by adding the same KG nodes and edges regardless of a patient's evolving state. We propose ReTA, a Reinforcement learning-based dynamic Topology Augmentation framework that casts KG import as a per-visit, budget-aware policy. ReTA first constructs an offline refined pool of KG-grounded templates, then learns a policy to select one augment action per visit from three options: Soft Import, which enriches node features without modifying graph topology, Hard Import, which grafts a compact KG subgraph onto the visit graph to create message-passing shortcuts, and Skip, which leaves the visit unaugmented when the base encoder is already confident. To stabilize learning, ReTA employs a decoupled encoder that processes semantic and structural signals in separate channels and fuses them via adaptive gating. Experiments on MIMIC-III and MIMIC-IV across diagnosis prediction, mortality, and readmission show that ReTA consistently outperforms strong baselines while remaining efficient, transfers across datasets and knowledge graphs, and yields interpretable augmentation patterns. The robust gains under sparse supervision highlight the advantage of ReTA's dynamic decision to import knowledge, boosting accuracy while curbing costs.

Linear classifiers trained on hidden states of a large language model (LLM), linear probes, can flag factual errors from a single forward pass. Geometrically, that implies that true and false statements separate along a stable direction in hidden state space, i.e., the truth direction. Prior work disagrees on whether this generalises across input shifts, but the disagreement is hard to interpret because cross-dataset probe transfer experiments confound several kinds of input change at once. We isolate three such variables in medical question-answering (QA): writing style (register), domain (medical specialty), and corpus (dataset). We build a benchmark using 500 MedQA entries, each rewritten into four styles (textbook, patient, clinical note, colloquial), annotated with clinical specialty, and grouped with two other exam corpora, MedMCQA and MMLU-medical, for cross-dataset evaluation. Probing four open-weight LLMs (2--8B), we find that the truth direction is largely robust to writing style (mean $Δ_\text{register} \approx 0.10$ AUROC on held-out facts) and to medical specialty ($Δ_\text{specialty} \approx 0.03$), but degrades unevenly across corpora: by $0.12$ AUROC on MMLU-medical and by $0.21$ on MedMCQA, roughly twice the register gap. The register result replicates with a second generator and carries over to human-written patient questions. The truth direction is therefore largely stable within the medical domain but breaks under some corpus shifts, and question format does not explain the break, which suggests that the signal a linear probe recovers is partly bound to dataset structure rather than to medical knowledge alone.

Multimodal coding and editing systems must map a visible or semantic referent to the exact executable object that can be edited. A wrong reference may select a valid but incorrect DOM node, SVG element, graph endpoint, hierarchy member, or table cell, while final execution success alone does not reveal the source of the failure. ExBind isolates this visual-to-executable correspondence layer as a controlled diagnostic benchmark between semantic localization and action execution. It samples representation-independent latent binding instances and compiles them into SVG, DOM, canvas, tree, graph, and table cases with deterministic mappings to executable references. Models output only a strict reference; the evaluator maps predictions back to latent structure and scores structural constraints without requiring reasoning traces. The release contains a 250-case broad suite, a disjoint 240-case targeted suite, and 50 paired latent groups. Qwen2.5-VL-3B achieves 98.4% candidate validity but 76.4% exact accuracy, while Qwen3-VL-4B achieves 100.0% validity and 98.8% exact accuracy. In the targeted table suite, all Qwen2.5-VL-3B residual errors are valid correct-row/wrong-column selections. Candidate-order perturbations change case-level outcomes while preserving this error pattern. ExBind is designed for controlled diagnosis rather than population-scale ranking or end-to-end editing evaluation. Code and benchmark records are available at https://github.com/Daerwang2020/Exbind and https://huggingface.co/datasets/Ziqianwwww/ExBind.

Clinical LLM assistants must reason over multi-visit patient trajectories, yet whether the compact history representations used to scale them---retrieval, structured timelines, LLM summaries, agentic memory---preserve the longitudinal signal clinical reasoning needs has not been measured. We introduce ClinTraceBench: 385 MIMIC-IV-derived verified dialogues with event-ID provenance, a nine-task taxonomy (T1--T9), and L0--L4 deterministic + L5 human-audit validation (98.92% agreement). We evaluate eight history representation strategies---a no-context floor, \textit{last-visit-only}, \textit{full-context}, BGE-M3 \textit{dense-retrieval}, two compression schemes, and two agentic-memory systems (\textit{Mem0}, \textit{A-Mem})---across four backbones (DeepSeek-V3, GPT-4o-mini, Haiku4.5, Sonnet4.6) on 6{,}271 questions: 32 cells, 200{,}672 predictions. Four findings: (SP4) a controlled T3 injection probe isolates compression-induced \textit{relation} loss---with the attribution sentence present \textit{before} construction, \textit{Mem0}, \textit{A-Mem} and \textit{llm-summary} still recover only 0--5.3% of the injected positives; (SP1) compressed strategies pay an aggregation tax on multi-visit trends and cross-patient comparisons; (SP2) the blind-to-full gap spans $+29.8$~pp (GPT-4o-mini) to $+62.7$~pp (Haiku); (SP3) abstention scales non-monotonically with context length. On the Pareto frontier Haiku dominates Sonnet under \textit{full-context} ($25.76 vs.\ $106.21), inverting the ``biggest backbone wins'' heuristic.

Reliable disaster damage assessment requires models that provide both accurate predictions and transparent explanations. However, existing multimodal approaches are limited by scarce annotated data and insufficient evaluation of reasoning quality. This study proposes a two-stage training framework that integrates Supervised Fine-Tuning (SFT) and Direct Preference Optimization (DPO) within a unified data construction pipeline. From a single Human-in-the-Loop (HITL) annotation workflow, two complementary datasets are derived, namely ReasoningSet, which contains validated rationales for SFT, and PreferenceSet, which comprises paired rationales for DPO-based alignment. The framework evaluates both classification performance and explanation quality using automatic metrics, model-based scoring, and human ranking. Experimental results show that SFT improves accuracy from 73.64% to 78.29% and increases Macro-F1 by 29% compared to the baseline, while explanation quality improves by approximately 25%. Subsequent DPO alignment further enhances interpretability on the PreferenceSet. Cross-model validation on InternVL-3-8B and LLaVA-1.5-7B demonstrates the robustness and generalizability of the approach. The proposed framework improves detection of underrepresented mild damage cases, reduces high-risk misclassifications, and strengthens alignment between model reasoning and human judgment. Overall, it provides a reproducible pathway to develop reliable multimodal systems that deliver auditable, actionable disaster insights for emergency management.

The rapid advancement of vision-language models (VLMs) has accelerated progress in computational pathology; however, whole-slide image (WSI)-based pathology report generation remains limited by the scarcity of large-scale WSI--report datasets and the complexity of mapping spatially distributed visual patterns to structured clinical text. To address this, we introduce a clinically curated Pan-Asia WSI--report dataset of approximately 10,500 pairs from five institutions and establish the REG 2025 benchmark through a MICCAI challenge for systematic evaluation of multimodal models. We analyze submitted methods spanning pretrained VLMs, multiple-instance learning frameworks, hierarchical expert models, retrieval-augmented generation, and cross-modal Transformers. Rather than indicating that VLM use alone was sufficient for superior performance, the results suggest that top-performing methods benefited from structured report representations, hierarchical diagnostic decomposition, and effective multimodal grounding. We identify key limitations, including instability in quantitative attribute estimation (e.g., numeric hallucination) and a tendency toward diagnostic overspecification, with some errors resembling known diagnostic pitfalls in routine pathology. These findings establish REG 2025 as a benchmark for evaluating WSI-based structured report generation and vision-language understanding in computational pathology, providing insights for the design of clinically grounded multimodal pathology models.

Large language model (LLM) agents are increasingly proposed for healthcare tasks such as clinical documentation, evidence retrieval, patient messaging, and care coordination. Yet many evaluations remain limited to static medical question answering or one-shot generation, under-representing longitudinal state, interruptions, and human handoffs. We introduce an episode-level evaluation protocol for healthcare NLP agents. The protocol separates evidence across model, agent, and simulated-workflow behavior; specifies a five-field episode schema; and defines annotation and scoring for state continuity, evidence traceability, and escalation decisions. It is instantiated as four task templates: documentation update, evidence retrieval, patient messaging, and triage handoff. The protocol does not claim to measure clinical outcomes or deployment value. Instead, it supplies a reproducible intermediate evaluation layer between static benchmarks and prospective workflow studies, with an explicit cost-sensitive treatment of missed versus unnecessary escalation.

When information extraction fails, a natural instinct is to improve the model doing it: for example, by scaling it up or refining its reasoning. In this paper, we show that another part of the pipeline matters at least as much: the queries used to elicit this information. Across four clinical benchmarks and five LLMs, improving the question design alone raises performance by 18.6 F1-score points, i.e. more than using larger extraction models. To make such question design learnable, we introduce List of Questions (LoQ), which generates document-specific question sets, and FeedQ, a feedback-driven optimization method that iteratively refines questions against extraction outcomes. The resulting optimized questions can be used to train lightweight generators: with fine-tuning, 4B-parameter models match or outperform expert-derived baselines and substantially exceed the performance of much larger untuned models. We release a dataset of 12,820 optimized questions to support a broader shift in information extraction research toward treating question design as a first-class problem.

Ambient AI scribes draft clinical notes under the reassurance that a clinician signs every note. We audited three commercial AI scribes on the same 142 consultations: 565 notes from recorded UK primary-care and US ambulatory encounters plus authored scenarios. Twelve discovery passes proposed 13,678 candidate errors; the 5,898 clearing an importance filter went to an adversarial panel of two models from different families, each told to refute what it could, and 618 survived. One note in three (31.3% [27.0, 35.6]) carries a verified failure, concentrated in allergy and medication information, invented patient identity, and history written up as examination on telephone consultations that can contain none. No product was given a patient record; setting aside the two classes a record would have prefilled, invented identity and dates, the rate is 24.8% [20.8, 29.0]. One failure mode did not fit our scheme, drawn from published scribe-error taxonomies: a treatment the clinician retracts, recorded as delivered care. Two clinicians adjudicated blind, disjoint samples: a physician author upheld 20 of 21 findings (95.2% [77.3, 99.2]) and an independent clinician, not an author, 12 of 12 ([75.8, 100]); both judged every sampled refusal genuine. A failure rate depends on the instrument as much as the scribes. With model, evidence and settings fixed, the review instruction alone moves the share of candidates verified from 9.3% to 79.0%, and the reviewing family moves it too: alone at that instruction the gentler flags 54.8% of notes against 27.8%. Between 28% and 97% of sampled notes carry a failure depending on the standard. Published audits disagree among themselves by a margin instrument differences alone can produce: omission is 54-86% of their errors against our 23.1%. We release all 618 findings with transcript-side evidence, every prompt and model version, and the re-runnable pipeline.

Ambient AI scribes draft clinical notes, and published audits find their dominant error is omission: information the encounter established that the note fails to record. The standard check is an LLM judge: a second model reads the note against the transcript and flags problems. We ask whether judges detect omissions. Public corpora cannot supply the answer key: their clinician reference notes and transcripts are materially discrepant. Our benchmark has 500 single-error note pairs from audited fact sheets, 298 with a named fact certainly absent and 202 added-or-altered controls. Across eight judge designs, paired discrimination (the flawed note below its clean twin, 0.5 a coin flip) reads 0.79-0.94 on added or altered content and 0.50-0.63 on omissions. On single notes, no design flags omissions reliably more often than perfect notes. Wording changes, voting and GEPA prompt optimisation move the operating point without creating usable detection. Restructuring the task recovers it: list the facts the transcript establishes, then check the note for each. Two methods reach it independently and trade off: a per-fact pipeline, and a GEPA-evolved prompt doing the same in one call. The pipeline's flags name the missing fact and its severity at 2.7% false alarms. The single call detects more (36.9% against 24.6%, p=0.002) at 6.2% false alarms and a tenth of the cost per note. A physician author validated 70 items and, where the two routes disagree, sided with the pipeline on 10 of 10 (p=0.002). A second clinician, not an author, graded the severity rubric blind and agrees to within a grade. On real vendor notes from a companion census no benchmark threshold transfers, but the re-calibrated single call detects more than the best of the eight at half its false-alarm rate. Omissions whose fact is restated elsewhere defeat both routes. We release the benchmark, prompts and judgements.

Designing models that generalize effectively in low- to medium-data regimes remains a primary challenge in medical machine learning, particularly for physiological time-series classification. While tabular foundation models such as TabPFN offer an attractive alternative to conventional fine-tuning through in-context learning, they are not designed to capture the temporal dependencies inherent to physiological signals. ~In this paper, we introduce TSPFN, a foundation model that redesigns TabPFN's architecture for time series data. TSPFN integrates structured temporal representations and positional embeddings to capture intra-sample temporal and channel dependencies. To fully leverage its spatio-temporal design, the model is pretrained on 140,000 real-world physiological time series across multiple medical domains. This yields a unified, generalizable framework capable of learning the specificities of medical time series. Experiments across diverse physiological benchmarks demonstrate that TSPFN consistently outperforms standard tabular baselines and TabPFN, and achieves superior cross-domain generalization compared to specialized deep time-series models. All our experiments, ablation studies, and pre-processing scheme are publicly available at https://github.com/Jeremstym/TSPFN

Cardiac magnetic resonance imaging (CMR) produces rich sequential data such as temporal cine videos and spatial LGE/mapping stacks, yet most deep learning approaches process individual 2D slices, discarding this context. We present MR-JEPA, a self-supervised video foundation model for CMR that extends LeJEPA to 3D spatiotemporal inputs through tubelet tokenization, spatiotemporal masking augmentation, and initialization from a 2D CMR foundation model. Unlike prior CMR video models limited to cine data, MR-JEPA is pretrained on multi-sequence data (cine, LGE, mapping) from 10,505 patients across two centers without annotations. We evaluate the frozen encoder on six downstream tasks using a unified multi-view gated attention architecture: LV ejection fraction, RV ejection fraction, three myocardial strains (GLS, GCS, GRS), and four-class disease detection. MR-JEPA outperforms other compared methods on all five regression tasks, including both a domain-specific CMR model pretrained on more data with text supervision and a natural-video foundation model, achieving an LV EF MAE of 4.79% (r =0.764) and a GLS MAE of 1.87 (r=0.805), with 21-27% MAE reductions over baselines on strain tasks. For disease detection, MR-JEPA achieved a macro AUG of 0.868, remaining competitive with the domain-specific baseline despite using a fully self-supervised pretraining objective. These results demonstrate the potential of a unified video encoder for robust, multi-view utilization of diverse CMR sequences in clinical cardiac quantification and diagnosis.

Medical referral (directing patients to the appropriate hospital department) is a complex decision-making process requiring the synthesis of multimodal data, including patient narratives, laboratory indicators, and radiology imaging. While Large Language Models (LLMs) have advanced medical dialogue systems, they struggle with real-world referral tasks due to two primary limitations: (1) Information Overload, where models fixate on high-frequency disease terms while overlooking subtle but critical urgency indicators; and (2) Unstructured Collaboration, where existing multi-agent frameworks rely on loose dialogue that leads to semantic drift and confirmation bias. To address these challenges, we introduce MASGR (Multi-Agent Structured Graph Reasoning), a framework that treats referral not as a classification task but as a structured graph construction problem. MASGR deploys specialized agents to extract evidence from distinct modalities and coordinates them through a clinical reasoning graph. This graph forces agents to establish explicit logical connections between conflicting evidence. Furthermore, we integrate a knowledge-guided arbitration mechanism that prioritizes patient safety rules over standard diagnostic classification. Extensive experiments on real-world medical records demonstrate that MASGR significantly outperforms state-of-the-art LLMs and existing multi-agent systems, particularly in complex cases requiring the balancing of chronic disease management and emergency intervention. The AI contribution lies in the Multi-Agent Structured Graph Reasoning framework that transforms unstructured multi-agent dialogue into a verifiable logical graph construction. The engineering application is demonstrated through its deployment in a complex healthcare decision-making system to optimize the precision of complex medical referrals.

Electrocardiogram (ECG) interpretation requires knowledge of cardiology, electrophysiology, clinical diagnosis, ECG waveforms, signal acquisition, and instrumentation. Existing language-model benchmarks, however, primarily assess broad medical knowledge or interpretation of individual ECG signals and images rather than the broader contextual knowledge required for ECG interpretation. We developed ECGQuest, a literature-grounded resource for evaluating and fine-tuning ECG-specific language models. A GPT-4o-based pipeline generated questions from 23 ECG references and Computing in Cardiology proceedings from 2003-2025. The final dataset contains 10,904 unique True/False questions paired with their negated forms (21,808 Q&A pairs). We evaluated three commercial and 20 open-source language models on a held-out test set in a zero-shot setting. Five open-source models with 7-14B parameters were fine-tuned using Low-Rank Adaptation, with BERT and BiomedBERT included as supervised encoder baselines. Generalization was assessed on ECG-related subsets of MedMCQA and MedQA converted to binary True/False questions using official answer keys. Zero-shot accuracy on ECGQuest ranged from 49.5% to 74.4%, with GPT-5 performing best. General-purpose models outperformed medically specialized models, several models showed strong True/False bias, and encoder baselines performed near chance. Fine-tuning improved all open-source models by 6.5-14.1%. Fine-tuned DeepSeek-R1-Distill-Qwen-14B reached 76.3% accuracy, while a five-model voting ensemble reached 78.5%. On MedMCQA and MedQA, fine-tuning mainly benefited weaker or class-biased models and did not consistently improve strong base models. ECGQuest provides a reproducible benchmark for contextual ECG knowledge and shows that parameter-efficient fine-tuning can make smaller language models competitive with substantially larger commercial models.

Objective assessment of surgical technical skill is important for surgical training and structured feedback, but current workflows remain dependent on labor-intensive expert review. Existing automated approaches primarily focus on visual inputs and provide limited support for jointly studying operative performance, structured skill scores, and evaluator feedback. We introduce SurgSkill-Bench, an initial video-score-text benchmark-style dataset containing 214 surgical training simulation videos, six-dimensional OSATS scores, and expert free-text comments. We define two evaluation settings: video-only OSATS prediction for automated assessment and post hoc expert-comment-assisted prediction, where evaluator comments are available as auxiliary information. We provide controlled baseline experiments using representative frozen visual backbones, content-adaptive key-frame sampling, and a simple video-text co-attention fusion module. Under internal video-level validation, content-adaptive sampling improves video-only performance in this dataset, while evaluator comments provide additional score-related signal in the assisted setting. The best mean AUROC reaches 0.88 under dataset-specific median dichotomization. We further discuss evaluation constraints related to dataset scale, metadata completeness, and the interpretation of comment-assisted prediction. Code will be released publicly at a later date.

Depression and anxiety in older adults with Mild Cognitive Impairment (MCI) are frequently underdiagnosed due to limited access to care. Multimodal analysis of remote clinical interviews is a scalable screening approach, but existing methods have three limitations. First, they do not correct temporal misalignment across multimodal features extracted at different resolutions, inducing spurious cross-modal associations. Second, remote recordings exhibit uneven modality dropout, but missing values are often zero-filled, making them indistinguishable from valid near-zero measurements. Finally, they do not jointly attribute predictions to modalities, questions, and interview moments, limiting fine-grained clinical interpretation. We propose a Temporally-Aligned, Missingness-Aware, Interpretable (TAMI) multimodal fusion framework. TAMI aligns speech, language, facial, and physiological features within question-answer segments on a shared timeline, encodes modality-level missingness over time, and conditions fusion on question context. In interviews with 49 older adults with MCI, TAMI achieved area under the receiver operating characteristic curve (AUROC) scores of 0.68 (depression) and 0.69 (anxiety). Fine-grained temporal alignment of multimodal features produced the largest performance gain ($Δ{\geq}0.1$). Multi-level interpretability analysis revealed that depression classification relied on eyegaze and open-ended questions, while anxiety classification depended on eyegaze and head pose, with attribution uniformly distributed across questions. Using only responses to the open-ended questions (5.1min), the depression model achieved an AUROC score of 0.67, which was not significantly different from using the full interview (19min) ($p>0.05$). Our findings support designing interview protocols centered on open-ended questions for depression screening in older adults with MCI.

Combining whole-body magnetic resonance imaging (WB-MRI) with clinical variables has the potential to improve systemic disease diagnosis by leveraging complementary sources of patient information. However, structured clinical variables are often incomplete or missing, limiting the applicability of conventional multimodal fusion methods that assume fixed inputs. In this work, we propose TACTIC (Tabular-Attribute Conditioned Transformer for Image Classification), a prompt-based multimodal framework that integrates WB-MRI and structured clinical data through conditional visual feature learning. By encoding clinical attributes as prompts, TACTIC supports an arbitrary number of tabular inputs and naturally handles missing data without requiring imputation or fixed input structures. We evaluate TACTIC on five WB-MRI classification tasks spanning systemic and oncologic applications, including diabetes, chronic obstructive pulmonary disease (COPD), breast cancer, prostate cancer, and metastasis diagnosis. Across all tasks, TACTIC consistently improves performance over image-only baselines when clinical information is available while maintaining strong predictive capability under incomplete tabular inputs. Our results demonstrate the effectiveness of prompt-based models as a flexible approach for improving WB-MRI analysis using clinical context. The model weights and code are available at https://github.com/lauradaza/TACTIC

Molecular toxicity prediction is increasingly used to prioritise compounds before experimental testing, but conventional benchmark performance can overstate practical utility when structurally related molecules occur across training and test folds. We introduce ToxLens, a reproducible multi-task graph-learning framework for 11 toxicity endpoints spanning Ames mutagenicity, acute oral toxicity, hERG inhibition, and Tox21 nuclear-receptor and stress-response assays. The workflow combines conservative chemical curation, sphere-exclusion filtering, a leakage-aware UMAP-HDBSCAN split, parallel graph and global-feature encoders joined by late concatenation, temperature-scaled Monte Carlo dropout with conformal-style prediction sets, applicability-domain analysis, and SHAP-guided toxicophore discovery with occlusion controls. On the leakage-controlled test fold, a five-seed soft-voting ensemble achieved a Matthews correlation coefficient score of 0.44, an area under the receiver operating characteristic curve score of 0.83, and an area under the precision-recall curve score of 0.58. It exceeded four ECFP4-based shallow baselines on all 11 endpoints under the same split and validation-based threshold-selection protocol. Controlled ablations showed that the global pathway was important, whereas late concatenation outperformed the tested gated and feature-wise linear modulation fusion variants. Conformal-style prediction sets revealed substantial endpoint-specific variation in set efficiency, and discrimination and calibration improved with similarity to the training domain. Retraining on fixed published Tox21 Challenge and TDA folds produced competitive, but not uniformly state-of-the-art, performance. SHAP-guided occlusion and consensus subgraph mining yielded model-derived structural hypotheses, 44 of which contained at least one occurrence that passed the predefined counterfactual criteria.

Medical knowledge changes continually, making large language models vulnerable to relying on outdated yet clinically plausible information. We study whether the format of supervision affects medical knowledge updating under a matched training-budget setting. We introduce SEER-Bench, a temporally anchored oncology-staging benchmark curated from the latest versioned SEER Research Data release, and render identical medical update events from NCCN oncology guidelines into four supervision formats: EMQ, MSQ, FITB, and SAQ. Across SEER-Bench and HealthBench Professional, EMQ gives the most stable external transfer and retention among same-budget SFT variants. With EMQ supervision, the updated 4B model produces competitive results on temporally anchored oncology staging, reaching 64.8% answer accuracy and 59.6% rationale accuracy on SEER-Bench. Diagnostic analyses suggest that EMQ exposes denser clinical contrast signals while preserving discriminative representations with smaller movement from the base model. These results show that medical knowledge updating depends not only on the update algorithm, but also on how knowledge is structured as supervision.

Clinical artificial intelligence is increasingly embedded in real-world care, yet existing safety mechanisms are poorly suited to reconstructing and learning from individual AI-related errors and near-misses. Aggregate model monitoring can identify performance changes, and traditional patient safety reporting can capture adverse events, but neither is designed to explain how risk emerges across the interaction among AI systems, clinicians, workflows, and institutional controls. We propose AI Morbidity and Mortality (AI M&M), a structured, blameless framework for case-based review of clinical AI failures. The framework combines standardized case intake, evidence preservation and investigator-level reconstruction, tool-in-loop attribution, and corrective-action tracking. Each event is classified across four linked dimensions: Trigger - Mechanism - Clinical Pathway - Corrective Action, separating the condition that exposed a vulnerability from the process that produced risk, its consequence for care, and the remediation assigned. We demonstrate the framework using five illustrative outpatient medication and clinical decision-support cases; two clinician reviewers independently applied all four classification axes and reached agreement across all 20 axis-level classifications. AI M&M is intended to complement, rather than replace, model monitoring, patient safety reporting, and regulatory oversight by converting individual AI-in-workflow failures into actionable institutional learning. Prospective evaluation across institutions, AI systems, and clinical settings is needed.

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.

Automatic medical coding assigns ICD codes to clinical notes, but it remains challenging due to long documents, imbalanced label distributions, and diverse terms. These challenges are especially severe for rare codes, which have limited training instances and are easily confused with semantically similar labels. We introduce CoLa-ICD, a knowledge-enhanced framework for long-tail prediction. CoLa-ICD enriches ICD labels with external terms, models dependencies among related codes, and learns stronger alignment between label semantics and clinical evidence for long-tail prediction. Experiments show that CoLa-ICD improves long-tail prediction with larger gains in larger and sparser label spaces and achieves state-of-the-art performance in AUC, F1, and P@k. Our code is available at https://github.com/youwillbethebest/Cola-ICD.

Large language models can convert medical documents into structured data, but plausible output may still be unsupported by the source. Persisting such output in a longitudinal health record, a record that accumulates patient information over time, therefore creates an integrity risk: unverified data may influence later summaries, trends, or preventive-care computations. We introduce an evidence-gated trust-promotion model that keeps generated data provisional until a deterministic monitor verifies it against the source document. The monitor admits a candidate for a specified downstream use only when the source contains a unique supporting quotation, the relevant fields occur within the same laboratory row, and the required provenance is preserved. The generator cannot approve its own output, missing or ambiguous evidence causes refusal, and refused candidates remain available for human review rather than being silently discarded. We implement the model in Medical DataCloud, a personal health-record application, and evaluate it through automated tests and a replay of saved extraction outputs. All 22 conformance and mutation tests pass. The replay covers nine historical laboratory PDF reports containing 102 manually labelled rows. The reports produce 97 numeric candidates: schema validation accepts all 97, an earlier packet-level evidence check accepts 94, and the hardened quotation- and row-level policy admits 72 while retaining 25 for review. The study evaluates system integrity rather than clinical correctness or clinical safety. The results demonstrate the technical feasibility of an enforceable boundary that prevents generated claims from authorizing their own reuse in a longitudinal health record.

Electronic Health Record (EHR) prediction models in the intensive care unit must learn from sparse and irregular measurements while preserving the clinical meaning of time and supporting transparent decision-making. We present INTERVenE, a family of Transformer architectures whose input is an interval-based, knowledge-based temporal abstraction (KBTA), a token stream of named clinical concepts (states, trends, events, contexts) drawn from a curated medical ontology, rather than an unnamed bin index or a raw measurement triplet. This naming layer is what we ask KBTA to do: it makes the model's per-token attributions resolve to clinical concepts by construction. INTERVenE offers two complementary variants: an auto-regressive decoder that generates future abstraction trajectories with a per-step risk readout (localizing \emph{when} and \emph{after which events} risk rises), and a bidirectional encoder for single-pass joint risk and time-to-event prediction. Evaluated on 57,078 MIMIC-IV admissions against GRU-D, STraTS, and KarmaLego, INTERVenE-Enc reaches a support-weighted AUPRC$_w$ of 0.672, improving by 0.041 over the strongest neural baseline with non-overlapping 95% bootstrap CIs, while also taking the best AUROC$_w$ (0.901) and length-of-stay MAE (44.4,h). INTERVenE-Ar (AUROC$_w$ $0.854$, AUPRC$_w$ $0.587$ under the same evaluation contract - a strictly harder generative readout) provides a complementary token-level risk trajectory. An input-representation ablation confirms the lift transfers across structured discretizations, positioning KBTA-based intervals as the interpretable substrate that makes per-token attributions resolve to meaningful clinical concepts within the deployed model.

Biomedical Named Entity Recognition (NER) is fundamental to healthcare AI applications, including clinical decision support and medical information extraction. While corpora with Unified Medical Language System (UMLS) annotations, such as MedMentions, have driven progress in English biomedical NER, no comparable resource exists for Vietnamese. This paper presents En-ViMedNER, the first English-Vietnamese parallel biomedical NER corpus annotated with UMLS semantic types, which are language-neutral codes providing a shared cross-lingual label space and ensuring direct comparability with existing UMLS-based resources. The corpus contains 4,392 PubMed abstract pairs, 44,892 English-Vietnamese sentence pairs, and 202,949 aligned entity-mention pairs across 21 semantic types adapted from the MedMentions ST21pv dataset. To balance quality and scalability, we have constructed the corpus through automatic translation, expert post-editing, LLM-assisted label projection, and human verification and adjudication. We characterize En-ViMedNER as a large-scale silver-standard corpus with a human-audited and consensus-corrected mini-test subset. We evaluate En-ViMedNER in two settings: (i) Vietnamese-input/Vietnamese-output biomedical NER and (ii) English-input/Vietnamese-output cross-lingual NER. For Vietnamese NER, we benchmark Vietnamese-supervised encoder models, English-supervised multilingual encoder models, and prompt-based LLMs. The best model achieves an F1 score of 52.70 on the test set and 53.78 on the mini-test set. For cross-lingual NER, we benchmark encoder-decoder models and prompt-based LLMs. The best model achieves an F1 score of 45.44 on the mini-test set. We publicly release our corpus, corpus construction pipeline, and baseline models to facilitate future Vietnamese biomedical NLP research.

Background: Patient details and acquisition metadata are important for clinical decisions, image quality control, and automated research pipelines, but may be missing or unreliable in imaging archives. Purpose: To develop and evaluate a fast open-source model that predicts patient and acquisition characteristics directly from CT and MR images. Materials and Methods: Separate 3D ResNet-10 ensembles for CT and MR were trained on 57,291 and 43,200 clinical examinations acquired from 2011 to 2025. Both predicted weight, height, age, sex, contrast presence, vertebral coverage, and image noise. The CT model additionally predicted scanner manufacturer, tube voltage, tube current, convolution kernel, and post-injection time; the MR model predicted sequence class. Performance was evaluated on internal CT (n=501) and MR (n=636) test sets and an external CT dataset (n=54). Results: Internal CT MAEs were 3.90 kg, 3.68 cm, and 4.42 years for weight, height, and age, with sex F1=0.990; corresponding MR results were 4.34 kg, 4.62 cm, 7.13 years, and F1=0.970. The CNN outperformed a segmentation-derived XGBoost baseline for all four core targets in both modalities (adjusted P<=.042). F1 scores were 0.963 for CT contrast, 0.953 for MR sequence, and 0.823 for MR contrast. External CT MAEs were 4.45 kg, 4.05 cm, and 5.17 years, with sex F1=0.971. CPU inference required 20 seconds for CT and 12 seconds for MR. Conclusion: One 3D multitask model per modality can rapidly recover patient and acquisition characteristics from heterogeneous CT and MR examinations. Models are available in TotalSegmentator: https://github.com/wasserth/TotalSegmentator

Reliable evaluation of vision-language models (VLMs) and medical vision-language models (Medical-VLMs) requires calibrated confidence, particularly under realistic clinical conditions. However, existing efforts mainly focused on improving accuracy, leaving calibration in the medical domain underexplored. To this end, we propose MVC-Bench, a calibration-centric benchmark for medical image classification with VLMs and Medical-VLMs. MVC-Bench assesses the calibration across three axes: (i) robustness to modality, backbone, and domain shift (ii) effectiveness of calibration strategies and prompt-tuning methods (iii) stability under prompt-template and random-seed variations. The benchmark covers eight different backbones, three medical modalities, including fundus imaging, histopathology, and chest X-ray under in-domain and domain shift settings. It compares post-hoc calibration, train-time calibration, and zero-shot inference methods, together with six prompt-tuning methods. Across more than 1638 controlled experiments, we report accuracy and Expected Calibration Error (ECE) as primary metrics, and further report results with complementary calibration measures, including Maximum Calibration Error (MCE) and Adaptive Calibration Error (ACE). We further investigate the underlying causes of miscalibration in VLMs and Medical-VLMs and propose a simple train-time calibration method, Multi-Class Margin (MCM) regularization, which achieves lowest ECE on 10 out of 12 settings in in-domain and remains competitive under domain shifts. Collectively, MVC-Bench provides a structured evaluation framework and actionable guidance for improving calibration in safety-critical medical workflows.

Lung cancer tissue diagnostics is complex, as therapy decisions in precision oncology rely on the integration of histomorphological, immunohistochemical, and molecular features. Yet pathological assessment remains largely visual and semi-quantitative and shows interobserver variability, while existing artificial intelligence (AI) tools cover only selected tasks, rarely reach generalizable expert-level performance, and lack prospective clinical validation. To address these challenges, we developed and clinically validated LUCAID, an agentic AI system for precision lung cancer pathology. An integrative agent couples diagnostic reasoning with nine modules that cover the full routine workflow, from quality control, tumor detection and segmentation, histological subtyping, tumor microenvironment profiling, tumor cellularity quantification, and predictive biomarker scoring (PD-L1, MET, TROP-2) to automated structured report generation. LUCAID enables users to interactively query the module outputs and generate reports that contextualize the results. Against large-scale expert ground-truth annotations, the analysis modules achieved F1 scores of 0.82-0.95. In prospective clinical validation, LUCAID reached 93.0% concordance with an expert-panel adjudicated reference standard across clinically actionable decisions, compared with 68.3-81.1% for five experienced thoracic pathologists.

Objective. To develop and evaluate a cuffless continuous blood pressure (BP) estimator using temporal physiological and demographic features. We propose a hybrid Transformer framework to estimate diastolic and systolic BP from ECG/PPG-derived feature sequences. Approach. Rather than raw waveforms, the framework models 10-step sequences of six physiological descriptors and two demographic covariates. A Multi-Source Temporal Encoder Module combines Transformer, Kolmogorov-Arnold Network, and XGBoost branches to capture complementary temporal, nonlinear, and tabular information. A Dynamic Conditional Fusion-Decoder applies differential multi-head attention, token-weighted aggregation, and gated residual correction. A robust composite objective jointly optimizes DBP and SBP. Main results. Using the MIMIC-III Waveform and Clinical Databases, the source pool comprised 28,486 waveform segments from 203 subjects, and feature generation retained 53,621 observations from 166 subjects. On 2,431 segment-level held-out test windows, mean error +/- standard deviation was 0.41 +/- 3.74 mmHg for diastolic BP and -1.60 +/- 5.95 mmHg for systolic BP, with 95% limits of agreement of [-6.93, 7.74] and [-13.25, 10.06] mmHg, respectively. The proportions within 10 mmHg were 98.48% and 94.36%. The framework achieved the lowest standard deviations and narrowest limits of agreement among the locally retrained baselines. Significance. The feature-sequence fusion framework improved agreement with reference BP and fell within numerical AAMI and BHS Grade A thresholds on this split. This retrospective analysis is not formal device validation; subject-disjoint and external evaluation remain necessary before clinical use.

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.

Magnetic Resonance Imaging (MRI) interpretation is fundamental to clinical decision-making, requiring radiologists to integrate multi-view anatomical planes across sequential timepoints while precisely localizing interval changes. However, existing vision-language benchmarks remain confined to single-timepoint, single-view interpretation, failing to capture the temporal-spatial reasoning essential to radiologic practice. We introduce the Time-Aware Multi-View MRI Benchmark, an evaluation framework unifying multi-view anatomical input, temporal reasoning across longitudinal scans, and structured localization guidance. The benchmark comprises 3,920 expert-verified question-answer pairs derived from 890 patients across over 3,200 longitudinal MRI timepoints, drawn from seven clinical cohorts covering glioblastoma, neurodegeneration, vestibular schwannoma, and brain metastases, in open-ended, multiple-choice, and binary formats, requiring models to identify anatomical regions of maximal change, characterize progression across sequences and views, and provide structured guidance specifying boundaries, imaging features, and confounders. Experiments across 16 vision-language models reveal moderate temporal alignment but systematic failure on change direction recognition and volumetric quantification, while multi-view inputs improve spatial localization yet degrade temporal reasoning in compact architectures. Our benchmark provides a systematic framework for evaluating progression tracking, interval change localization, and temporal ordering, which are essential for clinical deployment. Code, evaluation splits, and the dataset are available at: https://github.com/wafaAlghallabi/Time-Aware-MRI.

Electrocardiography (ECG), photoplethysmography (PPG), and phonocardiography (PCG) provide complementary views of the same cardiac cycle, yet existing cardiac foundation models are trained for a single sensing modality, leaving the shared physiology across sensors unexploited. We introduce CardioState-JEPA, a cardiac foundation model to learn a single shared representation jointly across ECG, PPG, and PCG, built on a physiology-aware joint-embedding predictive architecture. The model maps heterogeneous waveforms into a common token space, processes them with a single shared Transformer encoder, and learns by predicting masked latent cardiac states, placing the pretraining target on shared physiology rather than sensor-specific waveform appearance. To handle the temporal offsets between electrical, mechanical, and hemodynamic events, cross-modal prediction uses a learned delay aligner that matches signals at the corresponding cardiac time. Because synchronized multi-sensor recordings are scarce, CardioState-JEPA first learns within-modality structure from abundant unimodal data and then uses paired data to align modalities in latent cardiac time. Evaluated as a frozen encoder across 25 downstream tasks spanning ECG, PPG, and PCG, our encoder improves average PPG classification by 8.2 AUROC points, PCG murmur detection by 18.8 AUROC points, and ECG classification by 15.5 AUROC points over the best self-supervised signal baseline and matches or exceeds cardiac models trained with privileged clinical text or supervised labels on several ECG benchmarks. These results establish that heterogeneous cardiac signals can mutually supervise a single foundation model of cardiac physiology.

Clinical intelligence requires estimating a patient's underlying condition from incomplete observations rather than learning isolated mappings from scans to answers. Volumetric medical images provide dense observations of anatomy, attenuation, and lesions, whereas clinical language provides sparse but complementary semantic observations. We formulate CT-centered intelligence as inference over a shared latent patient state, under which readout, reconstruction, and simulation all become state-dependent prediction problems. To operationalize this view, we introduce HounsBench, a computed tomography (CT) centric patient-state benchmark that unifies these three task families with patient-disjoint splits and per-family metrics, and HounsWorld, a 3B multimodal world model that treats volumetric scans and language as observations of the shared state through Joint Understanding-Generation Learning. A shared transformer forms an implicit patient-state estimate and supports three outputs: query-conditioned answers that read out the state, reports and captions that reconstruct it in language, and condition-specific CT volumes for low-dose denoising, virtual contrast enhancement, and anatomy-constrained text-and-mask-to-volume generation. Zero-initialized CT adapters preserve pretrained multimodal mappings, while condition-explicit Hounsfield-unit window sampling exposes clinically meaningful density observations. HounsWorld shows strong performance across all three task families while consistently improving CT understanding through clinically structured completion. Our project is available at https://github.com/byhwhite/HounsWorld.git

Access to clinical data is essential for developing reliable healthcare machine learning systems, but direct use of electronic health records is constrained by privacy regulation, institutional review, data-use agreements, and the risk of re-identification. Synthetic data promises a practical alternative: it can preserve useful statistical and clinical structure while reducing exposure of sensitive patient records. Prior studies often evaluate a single generator, one dataset, or a narrow downstream task, making it difficult to know when synthetic data can support model development and when it fails to preserve task-critical signal. We introduce CoMedBench, a reproducible benchmark that evaluates a family of generators under a common clinical-validity framework and one shared training and evaluation engine, spanning static tabular and temporal downstream tasks on established critical-care datasets. In total the benchmark spans 37 dataset-task pairs across two modalities consists of 20 static tabular and 17 temporal ICU time-series-drawn from seven public data sources: three intensive-care databases (MIMIC-III, MIMIC-IV, and eICU) together with the UCI Machine Learning Repository, the CDC BRFSS diabetes cohort (2015), NHANES (1999-2014), and the pycox survival datasets (GBSG and METABRIC). The benchmark evaluates both statistical fidelity and task utility by comparing models trained and tested across real and synthetic data. In these settings, synthetic training data preserves most of the downstream signal: on tabular tasks the reference generator CoMed-CTGAN retains a mean AUROC utility (the synthetic-to-real performance ratio) of 90.6%, rising to 97.3% for the strongest generator, CoMed-TVAE. Temporal ICU tasks are harder and more generator-sensitive: CoMed-CTGAN retains 81.6% (AUROC) and only 64.0% under the imbalance-sensitive AUPRC, whereas CoMed-TVAE still retains ~95% (AUROC).

Understanding the temporal progression of symptoms in clinical narratives is critical for disease monitoring, safety surveillance, and causality assessment. Clinical narratives, however, rarely provide explicit temporal anchors. Current approaches to temporal information reasoning focus predominantly on pairwise relation classification across multi-visit and timestamp-rich records, leaving the reconstruction of structured symptom trajectories from individual anchor-sparse reports largely unaddressed. We propose CRAFT, an LLM framework that pairs a generator with a constraint-based verifier to iteratively produce and refine stage-wise symptom timelines through targeted feedback. We conduct evaluation on MedTempo, a new benchmark of 5,347 vaccine adverse-event narratives spanning three COVID-19 vaccine types, with expert-validated temporal stage annotations for 3,166 reports. Experiments across four LLM backbones demonstrate that CRAFT consistently improves temporal ordering accuracy, with ablation analysis isolating the contribution of generator and verifier components across model capability levels.

LLM-based simulated clients are increasingly used to train novice counselors, evaluate LLM therapists, and generate synthetic data. However, current simulators produce overly cooperative clients that disclose too readily, accept therapeutic reframes without resistance, and resolve core issues within a single session. We trace these issues to profiles that lack causal depth and behavioral mechanisms that treat all content as equally accessible. We present PatientAct, a framework for client simulation grounded in established clinical theories. Our profiles integrate the 5Ps clinical case formulation, providing causal depth without tying the design to any single therapeutic modality. During simulation, profiles include a dynamic memory layer in which items carry trust thresholds (e.g., symptoms are available early, whereas formative memories require a sustained therapeutic alliance). At each turn, the client's emotional reaction and behavior are modeled before generating a response. If the therapist approaches gated content, PatientAct expresses resistance in terms of quantity, content, and style rather than defaulting to cooperation or a single resistance pattern. We evaluate our framework on 40 clinical situations and demonstrate that it generates diverse profiles with high clinical plausibility. Moreover, PatientAct significantly outperforms the baselines, yielding substantial gains in resistance quality and behavioral realism. Our code and data will be publicly available via github.com/Sahandfer/PatientHub.

Medical AI has demonstrated specialist-level diagnostic accuracy, yet these capabilities remain largely inaccessible in resource-constrained rural settings where bandwidth is scarce, compute is limited, and clinical decision-making requires integrating heterogeneous modalities. We introduce a cloud--edge collaborative architecture that addresses these constraints: lightweight, domain-specific models on the edge transform raw medical data into compact structured outputs, while a cloud LLM synthesizes these outputs into clinical summaries. An LLM-based orchestrator dynamically selects diagnostic tools based on patient context, promoting comprehensive modality coverage without processing irrelevant inputs. We evaluate on 20 multimodal clinical cases spanning cardiac, obstetric, trauma, and screening scenarios under three simulated network profiles (500,kbps--5,Mbps). The hybrid system achieves 98--99% diagnostic tool recall with 92--96% precision, matches or exceeds cloud-only baselines on clinical accuracy, and maintains bandwidth-invariant latency (25--35,s) at 4--15x lower token cost. These results highlight the role of architectural design in enabling efficient multimodal integration and improving factual grounding compared to cloud-only approaches under deployment constraints.

Self-supervised electrocardiogram (ECG) models are often trained on a few seconds of ECG signal and, increasingly, on discretized token sequences. It remains unclear whether these choices sacrifice information needed for rhythm inference and longitudinal consistency in real-world ambulatory recordings. We present a controlled study on the Icentia11k single-lead dataset that varies (i) the input horizon (16 seconds, 1 minute, 5 minutes, and 10 minutes) and (ii) the front-end representation (continuous convolutional patch embeddings vs. fixed vector-quantized tokens), while holding the Transformer backbone and training protocol constant. Representations are assessed by downstream abnormal rhythm detection and by patient-level retrieval that probes cross-session stability. Our results show that increasing temporal context beyond 16-second snapshots yields stronger transfer and higher retrieval accuracy, with the strongest performance achieved by the 5- and 10-minute models, indicating improved capture of slow-varying rhythm dynamics and individual-specific structure. Across all evaluated horizons, continuous patch embeddings outperform discretized tokens, suggesting that quantization can discard clinically relevant waveform detail. These findings motivate ECG foundation models that emphasize extended context and continuous encoders for clinical prediction and similarity-based applications. Our code and pretrained models are publicly available at https://github.com/muha-0/ecg-ssl-representation-learning.

Continuous physiological time series underpin modern clinical monitoring, yet many of the most informative signals are invasive, expensive, or simply unavailable for a given patient. Conditional generation offers a remedy: an absent signal can be synthesized from co-recorded signals and routine clinical variables. Existing generators, however, are built around a single conditioning modality and degrade when forced to handle the heterogeneous, irregularly missing mix of time-variant signals and static covariates seen in practice. We propose ReCoGen (Represent Conditions, then Generate), a two-stage framework that decouples multimodal condition representation from target generation. Stage I trains one masked autoencoder per modality, distilling each time-variant condition into a compact and missingness-tolerant token sequence. Stage II trains a flow-matching generator that fuses these tokens with static conditions to synthesize the target signal. Across three physiological benchmarks, including continuous glucose monitoring on AI-READI and arterial blood pressure generation on MIMIC-III and MIMIC-IV, ReCoGen attains the best downstream utility on all sixteen (dataset, task, metric) settings, surpassing six representative conditional generators; on thirteen of them its utility also reaches or exceeds the utility measured on the real signal, a reference we read as an approximate anchor rather than a ceiling. Ablations trace the gains to the conditioning path: learnable cross-attention over the frozen per-modality encoders, and a dual token-plus-AdaLN route for the static conditions. ReCoGen thus turns routinely collected signals into informative surrogates for invasive or unavailable ones, a step toward less invasive, lower-cost continuous clinical monitoring.

Clinical prediction models are often developed as if the outcome of interest were cleanly observed for every patient. This assumption fails when treatment decisions make the clinically relevant outcome permanently unobservable. As a case study of this problem, we consider post-cardiac-arrest neurological prognostication using a cohort of 2,497 patients, including 1,429 patients whose outcomes were rendered indeterminate by treatment decisions. These patients with indeterminate outcomes were reviewed by independent clinical experts, who provided their guesses of counterfactual outcomes about what would have happened to the patients. We refer to these patients as uncertain cases. We also have patients for whom we observe their clinically relevant outcomes; we refer to these patients as certain cases. We propose a framework for evaluating prediction models that explicitly splits the evaluation between certain and uncertain cases. Here, we cannot easily evaluate both types of cases in a uniform manner as the available target labels differ. We then propose a simple prediction model that uses target labels from both certain and uncertain cases in a manner that allows us to trade off between them. Across the proposed neural model and a collection of tabular baselines, models with similar certain-case AUROC can nevertheless differ substantially in both certain-case Brier score and their probability estimates for uncertain cases. Improving alignment with target labels of uncertain cases for our proposed model generally comes at the cost of worse accuracy on certain cases, highlighting an explicit tradeoff that standard evaluation conceals. These results show that when treatment decisions determine whether clinically meaningful outcomes remain observable, conventional evaluation metrics can miss important failure modes in the very patients for whom prognostic support matters most.

Deploying unsupervised domain adaptation (UDA) in clinical practice requires choosing which algorithm to use and which of its trained models to ship. However, the deployment (target) domain is unlabeled, so models cannot be evaluated directly on it, leaving it unclear which to select. We address this by evaluating the complete UDA pipeline, considering both adaptation and label-free selection together. Our study covers eleven clinically relevant cross-domain scenarios from nine medical imaging datasets, with ten UDA algorithms and 13 label-free selection methods (validators), evaluating over 80,000 trained models in total. By this, we find that a capable adapted model usually exists, but identifying it without target labels is difficult: the validator-selected models leave a large and structural target performance gap to the best available one, with no evaluated validator consistently reliable. Towards closing it, we explore two strategies, ensembling and a small target-labeling budget; both narrow this gap but do not close it entirely. Overall, deployable UDA depends on the complete pipeline; addressing the less explored selection step could bring much of current UDA closer to clinical use.

In medical imaging, the clinical value of Computed Tomography (CT) lies not only in depicting current disease status, but crucially in enabling longitudinal comparison of serial scans to determine disease evolution, a process that underpins response assessment, recurrence detection, and ongoing patient management. Yet, despite this central role of temporal comparison in clinical decision-making, existing medical foundation models remain largely confined to single-study understanding, leaving temporally grounded cross-examination insufficiently addressed. To address this gap, we study longitudinal imaging difference reporting, a task in which a model takes two temporally separated scans from the same patient and generates a clinically meaningful report describing interval changes between them. We introduce CT-$Δ$Bench, a dedicated benchmark for this task with patient-level splitting to prevent information leakage. To better evaluate this task beyond surface-level text similarity, we further develop change-aware metrics specifically designed to capture clinically meaningful longitudinal changes, and conduct an independent physician validation to assess the reliability of the synthesized references and event extraction pipeline. We also compare direct paired-CT reasoning with an indirect two-stage pipeline that first generates single-timepoint reports and then performs textual differencing. Finally, we propose DeltaMed, a baseline model for direct paired-CT difference reporting, and train it on the benchmark training set. Together, these contributions lay the groundwork for temporally aware medical foundation models that better reflect real-world longitudinal clinical reasoning.

Pancreatic cancer is among the most lethal malignancies; risk stratification of intraductal papillary mucinous neoplasms (IPMNs) offers a crucial opportunity for early intervention but typically requires invasive tissue biopsy. Dominant vision-based approaches, including radiomics and deep learning, provide promising but initially separate discrimination opportunities. Similarly, multisequence MRI (T1W/T2W) and anatomically decomposed (head, body and tail) analysis of the pancreas provide additional and potentially complementary signals. Effective fusion of this information is crucial in ordinal IPMN dysplasia risk prediction and can be accomplished via a meticulously regularized and calibrated ensemble stacking combiner. We present cUPMI, a class-conditional Gaussian augmentation of a combiner's log-probability meta-features, and test it on various prediction paradigms. In our multi-center analysis, we find cUPMI adds limited value to properly regularized L2-logistic binary classification stacks, but consistently regularizes higher-capacity tree combiners in the binary and radiomics-only setting (RF +0.015 and XGBoost +0.024 binary AUC, positive in all seeds). Its cleanest ordinal benefit appears for XGBoost on an 8-stream radiomics task (3-class no < low < high, +0.022 QWK in all seeds). Separately, fold-locked fusion of radiomics and 2.5D CNN streams yields the strongest overall model, an RF stack reaching QWK 0.595 (95% CI [0.54, 0.64]) and binary AUC 0.839, surpassing radiomics, 2.5D ResNet, and 3D DenseNet-121 baselines.

Drug response prediction (DRP) models are an active area of research in pharmacogenomics, with growing potential to accelerate the identification of effective anticancer drugs. However, their predictive performance is often constrained by limited dataset scale and insufficient coverages of cancer and chemical spaces. In addition, inconsistent benchmarking practices hinder reliable comparison across models. Standardized frameworks, such as the Innovative Methodologies and New Data for Predictive Oncology Model Evaluation (IMPROVE) project, provide unified data schemas and evaluation protocols for consistent benchmarking, but improving model generalizability requires larger and more diverse training data. In this work, we substantially expand the IMPROVE benchmark through large-scale integration of pharmacogenomic data, primarily from PharmacoDB, together with additional smaller data sources. The expanded resource includes millions of drug response measurements, broader multi-omics coverage, and a major increase in chemical diversity, adding more than 50,000 compounds. To evaluate the impact of the new dataset compared to the original IMPROVE benchmark dataset, we trained DRP models using the two datasets and assess their prediction performance using a common test set and several evaluation strategies, including drug-blind, cancer-blind, and disjoint data splits. While cancer-blind performance remained comparable to the original benchmark, models trained on the expanded dataset showed consistent improvements in drug-blind and disjoint settings, indicating enhanced generalization to previously unseen compounds. These results position the expanded dataset as a community resource that provides a richer foundation for developing DRP models intended to aid in the discovery of novel anticancer drugs.

Offline reinforcement learning (RL) offers considerable promise for optimizing ICU treatment decisions, yet standard evaluation metrics Mean Squared Error (MSE) and Fitted Q-Evaluation (FQE) assess only behavioral imitation and cannot detect Toxic Mimicry, a failure mode in which agents replicate harmful patterns such as treatment withdrawal during comfort-care transitions. Using the MIMIC-III database, we propose the Counterfactual Clinical Audit (CCA) framework, which stress-tests RL agents through physiological perturbations anchored in Surviving Sepsis Campaign (SSC) guidelines. We audit a Medical Decision Transformer (MedDT) and a Historical Causal Transformer (HCT-RL), the latter employing Causal Action Shielding, propensity-based importance weighting, and Conservative Q-Learning. CCA reveals that MedDT paradoxically reduces vasopressor dosage as lactate escalates, contradicting resuscitation guidelines, while HCT-RL maintains physiologically consistent responses. These findings expose a systemic misalignment between statistical fit and clinical safety, supporting counterfactual audits as a necessary evaluation standard for medical RL.

Clinical text can narrow down what to segment, but recent text-guided designs emphasize spatial alignment while overlooking frequency content that governs texture and boundaries. We propose Dual-Domain Cross-Modal Decoding (DD-CMD) for clinical text-guided pulmonary infection segmentation, integrating two complementary forms of language guidance during decoding. In the spatial domain, Text-Guided Spatial Cross-Attention (TGSA) aligns multi-scale visual tokens with text semantics and updates features through gated residual fusion. In the frequency domain, Spectral-Text Adaptive Modulation (STAM) applies a 2D DCT to compute learnable band-energy statistics and predicts text-conditioned FiLM parameters to recalibrate decoder channels for frequency-aware decoding. DD-CMD embeds TGSA and STAM into a coarse-to-fine decoder (7x7 to 56x56) and restores full-resolution masks using a lightweight two-stage refinement module. Experiments on QaTa-COV19 and MosMedData+ show that DD-CMD achieves 91.46% Dice / 84.26% mIoU and 81.95% Dice / 69.42% mIoU, respectively, with average gains of +1.96 Dice and +2.67 mIoU over the strongest prior baselines. Code: https://github.com/maklachur/DD-CMD.

High-resolution images of unprocessed surgical breast tissue can be obtained using microscopy with ultraviolet surface excitation (MUSE). This technique is considered a promising method for checking surgical margins during breast cancer surgery. In this study, MUSE images at 4x and 10x magnifications were compared using patch-level classification methods. Texture analysis (TA) based on local binary patterns (LBP) and deep learning (DL) with a base Vision Transformer (ViT) model were used. Both methods achieved similar performance at both magnifications. Using DL method, both 4x and 10x magnifications achieved 96.30% sensitivity, 100% specificity and 98.18% accuracy. Using TA method, 4x achieved better specificity (100% vs 93.33%) and 10x yielded higher sensitivity (100% vs 93.33%), but both had the same accuracy (96.67%). No clear improvement in performance was observed with 10x magnification. These results show that 4x imaging achieves the same diagnostic accuracy as 10x imaging. At the same time, 4x offers a larger field of view and faster image capture. Therefore, lower magnification can be effectively used in MUSE systems for accurate and efficient intraoperative margin assessment.

Feature-attribution methods such as SHAP provide useful evidence about individual model predictions, but their numerical outputs are rarely sufficient for audiences with different expertise, goals, and risks of misinterpretation. In medical AI, the same local explanation must reach patients, clinicians, and data scientists through markedly different forms of communication, and naive verbalization through large language models (LLMs) is prone to weak grounding, conflation of attribution with causal language, and outputs that are persuasive without being faithful to the underlying model evidence. We introduce XstrAI, an audience-aware multi-agent framework that treats local explanations as fixed evidence and structures how it is communicated to each target reader. Each prediction case is encoded as an immutable structured representation, shared identically across audiences so the underlying evidence remains fixed. Generation is factored into three specialized LLM agents responsible for audience-aware planning, linguistic realization, and validation for grounding, attribution consistency, communicative risk, and audience appropriateness, with a bounded revision loop triggered on detected inconsistencies. We evaluate XstrAI on diabetes and stroke risk prediction against 11 baselines, ranging from direct verbalization to a re-implementation of a state-of-the-art narrator. The evaluation combines an intra-narrative regime measuring fidelity to SHAP evidence with an extra-narrative regime assessing audience appropriateness through reference corpora, multi-family LLM judges, and a survey with target readers. In both evaluations, XstrAI's narratives are consistently assigned to their intended audience by independent judges, and preferred over all baselines on Clinician and Patient audiences, with competitive performance on Data Scientist, where audience-conditioned single-prompt baselines lead.

Reinforcement learning with verifiable rewards has been especially effective in mathematics and coding, where answers can be checked automatically. Many open-ended medical questions lack comparably cheap outcome verifiers: responses may be partly correct, incomplete, or contain clinically consequential errors. Rubrics written or validated by physicians offer strong clinical grounding, but involving experts in every instance is costly. Model-generated rubrics make this supervision scalable. We introduce ConRub-Med to preserve useful distinctions as rubric feedback moves from construction to policy optimization. For each prompt, three heterogeneous language models propose atomic criteria independently; a separate model reviews them, retaining only criteria with semantic support from all three generators. Three-State scoring distinguishes correct coverage, missing information, and incorrect claims. Errors receive negative rather than zero credit. When every response in a complete Group Relative Policy Optimization (GRPO) group receives the same final reward, a pairwise judge provides sequence advantages only if both candidate orders agree, without changing the scalar rewards. Groups without ties use vanilla GRPO. In a blinded study matched by question, two medical experts rate panels from the full pipeline as more clinically relevant than panels produced by one generator. Across the evaluated open models, ConRub-Med ranks first on six of nine benchmarks and achieves the highest medical and generalization averages. Using the resulting rubric dataset of 5,166 prompts, it scores $38.98 \pm 1.04$ (mean $\pm$ SD) on HealthBench-Hard, compared with InfiMed-ORBIT's 33.60 with 8,000 samples and 37.30 with 28,000.

Healthcare data, such as Intensive Care Unit (ICU) records, comprise heterogeneous multivariate time series sampled at irregular intervals with pervasive missingness. However, clinical applications demand predictive models that are both accurate and interpretable. We present our Graph Attention-based Relational Learning for Intensive Care (GARLIC) model, a novel neural network architecture that imputes missing data through a learnable exponential-decay encoder, captures inter-sensor dependencies via time-lagged summary graphs, and fuses global patterns with cross-dimensional sequential attention. All attention weights and graph edges are learned end-to-end to serve as built-in observation-, signal-, and edge-level explanations. To reconcile auxiliary reconstruction and primary classification objectives, we developed an alternating decoupled optimization scheme that stabilizes training. On three ICU benchmarks (PhysioNet 2012 & 2019, MIMIC-III), GARLIC sets the new state of the art in outcome prediction, significantly improving AUROC and AUPRC over best-performing baselines at comparable computational cost. Ablation studies confirm the contribution of each module, and feature-removal trials validate the fidelity of importance attribution through a monotonic performance drop (full > top 50% > random 50% > bottom 50%). Real-time case studies demonstrate actionable risk warnings with transparent explanations, marking a significant advance toward accurate, explainable deep learning for irregularly sampled ICU time series data. Moreover, we demonstrated \proposed{}'s superiority in data imputation and classification on various time-series datasets beyond the ICU domain, showing its generalizability and applicability to broader tasks.

Reinforcement Fine-Tuning (RFT) has enabled medical Multimodal Large Language Models (MLLMs) to produce Chain-of-Thought (CoT) reasoning for visual question answering, yet these models suffer from $\textit{confidence miscalibration}$---a systematic gap between expressed certainty and actual diagnostic accuracy that undermines clinical trust. We propose $\textbf{CARE}$, a $\textbf{C}$onfidence-$\textbf{A}$ware medical $\textbf{RE}$asoning framework that jointly optimizes accuracy and calibration through a dual-stage pipeline. First, a scalable Medical-CoT synthesis provides structured cold-start data for Supervised Fine-Tuning. Second, Group Relative Policy Optimization (GRPO) with a novel $\textbf{Confidence-Aware Reward (CAR)}$ mechanism ties the model's confidence to diagnostic correctness within the reward signal. Across three Medical VQA benchmarks, $\textbf{CARE}$ achieves the highest diagnostic accuracy while obtaining the lowest Expected Calibration Error and Hallucination Rate, establishing a foundation for trustworthy clinical decision support. Our code is available at https://github.com/anotherbricki/CARE.

While vision-language models dominate medical representation learning, unstructured text lacks the dense, quantitative diagnostic phenotypes inherent in structured clinical tables. However, existing multimodal pre-training methods underutilize this potential due to semantic-agnostic designs that treat tabular inputs as flat vectors and employ unstable continuous regression objectives. To overcome this, we propose a novel semantic-aware framework explicitly modeling the intrinsic two-dimensional structure of tabular data. First, addressing the inter-feature hierarchy of varying diagnostic importance, we introduce Importance-Aware Adaptive Masking to construct a label-free curriculum prioritizing salient features. Second, addressing the intra-feature continuity-discreteness duality, we propose a Soft-Label Discretized Module that replaces unstable numerical regression with stable distribution matching, thereby mathematically preserving ordinal relationships. Extensive experiments across large-scale dermatology (SLICE-3D, HOP) and ophthalmology (EyePACS) datasets establish a new state-of-the-art (SOTA), demonstrating exceptional robustness and cross-domain generalizability.

Hospital quality improvement (QI) programs routinely face multiple candidate interventions to optimize hospital flow, but existing methods struggle to estimate and rank the causal effects of such interventions. This work focuses on one of the most standard hospital metrics, the average length of stay (LOS), and its causal estimand, the average time saved. To characterize this causal effect, qualitative approaches rely on expert judgment to map patient trajectories, making them susceptible to cognitive biases; quantitative approaches rely on data-driven models, which fail when interventions are hypothetical with no historical data or have complex causal mechanisms that require clinical reasoning rather than data alone. We propose expert-guided g-computation, or egg-computation, which combines the complementary strengths of both approaches by connecting the Gantt charts commonly used to map patient trajectories with the causal DAG literature. We introduce a causal model over Gantt charts and establish identification using a variant of g-computation that seeks expert input only for components unidentifiable from data. To make egg-computation practical, we develop an LLM-assisted pipeline that reliably scales up expert reasoning. In simulations, egg-computation outperforms conventional causal inference methods when patients have diverse causal structures and intervention mechanisms. In a study of eleven candidate QI interventions at an urban safety-net hospital, the LLM pipeline generated graphs and time-saving estimates highly concordant with those of human experts. Beyond healthcare, egg-computation is a broadly applicable framework for estimating the average time saved for candidate interventions whose causal mechanisms can be represented using Gantt charts.

Multi-modal learning combining medical images and clinical text is promising for disease diagnosis. However, standard multi-modal training leads to shortcut learning: models exploit the easier modality (e.g., diagnostic cues in text) while neglecting harder-to-learn features (e.g., subtle visual patterns). We propose UniMod, a framework that mitigates shortcut learning by requiring each modality to predict the diagnosis on its own. It supervises image-only, text-only, and multi-modal classification simultaneously, so each modality must extract diagnostic features. We add cross-modality alignment for knowledge transfer and within-modality supervised contrastive alignment over same-diagnosis patients. On Harvard-Glaucoma, UniMod reaches 0.850 AUC, outperforming OGM-GE and Gradient Blending by 1.6-1.8%; on CheXpert Plus, it reaches 0.966 AUC, surpassing them by over 5%. UniMod also extends to 5-class multi-label diagnosis without architectural change, improving mean AUC by 0.097 over CGGM.

Electronic health-record interoperability is a boundary problem: legacy systems, generative models, terminology services, identity systems, and human reviewers may each expose rich internal states, while operational exchange requires a narrow shared interface of typed claims, bounded uncertainty, provenance, and explicit admission or abstention. This paper details a mathematical and engineering architecture for that interface. The organizing idea is the logit boundary: a discovery model may propose pre-threshold scores over a local categorical decision, but a deterministic judgment substrate decides whether the proposal is admissible, requires review, or must be quarantined before any Fast Healthcare Interoperability Resources (FHIR) transaction is constructed. The resulting Geometric Belief Interface (GBI) combines finite boundary semantics, local Dirichlet evidence, cellular-sheaf and mapping-cone diagnostics, advisory geometric audit charts, and a Decentralized Cryptographic Sheaf-Enclave (DCSE) protocol sketch for fail-closed deployment. The framework does not establish clinical truth, global representation alignment, or end-to-end safety; it defines certificate-producing checks at a model-to-system boundary. A companion frozen synthetic benchmark, GBI BoundaryBench v0.1, evaluated Qwen3-4B-Instruct-2507 on 256 held-out tasks across three evidence modes (768 canonical executions). All executions completed, but none produced an output accepted by the benchmark contract: 369 were rejected during safe parsing and 399 during schema validation, yielding zero coverage and deterministic quarantine. This empirical result is deliberately narrow - one 4B open-weight model under one frozen interface - and is reported as evidence about the admission boundary, not as a general claim about LLM capability or clinical safety. A Julia appendix verifies numerical certificates using standard libraries.