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01.
arXiv (CS.LG) 2026-06-17

A Generalized Sinkhorn Algorithm for Mean-Field Schrödinger Bridge

arXiv:2604.06531v3 Announce Type: replace-cross Abstract: The mean-field Schrödinger bridge (MFSB) problem concerns designing a minimum-effort controller that guides a diffusion process with nonlocal interaction to reach a given distribution from another by a fixed deadline. Unlike the standard Schrödinger bridge, the dynamical constraint for MFSB is the mean-field limit of a population of interacting agents with controls. It serves as a natural model for large-scale multi-agent systems. The MFSB is computationally challenging because the nonlocal interaction makes the problem nonconvex. We propose a generalization of the Hopf-Cole transform for MFSB and, building on it, design a Sinkhorn-type recursive algorithm to solve the associated system of integro-PDEs. Under mild assumptions on the interaction potential, we discuss convergence guarantees for the proposed algorithm. We present numerical examples with repulsive and attractive interactions to illustrate the theoretical contributions.

02.
arXiv (CS.CL) 2026-06-18

Approximate Structured Diffusion for Sequence Labelling

Sequence labelling, a core task of Natural Language Processing (NLP), consists in assigning each token of an input sentence a label. From a Machine Learning point of view, sequence labelling is often cast as a Linear-Chain Conditional Random Field (CRF) parametrised by a neural network. While this approach gives good empirical results, CRFs assume a finite decision span (eg label bigrams) which can limit their expressivity and hurt performance when long-range dependencies are required. We show we can leverage diffusion to train a CRF conditioned on an entire label sequence, with the caveat that the condition is on a noisy version of labels. We show experimentally that this method, in conjunction with approximate CRF inference, improves label accuracy with a 16.5% error reduction for POS-tagging.

03.
arXiv (CS.AI) 2026-06-15

CisTransCell: Single-Cell Perturbation Prediction via Gene Function, Regulatory Control, and Cellular Context

arXiv:2606.13713v1 Announce Type: cross Abstract: Predicting cellular transcriptional responses to genetic perturbations is a central problem in single-cell biology, especially in the zero-shot setting where the perturbed gene or gene combination is unseen during training. A major difficulty is that perturbation effects are not determined by expression state alone: they depend on how the perturbed gene product influences other genes and proteins, how those downstream factors act on cis-regulatory elements, and which regulatory programs are active in the current cell state. To better capture this biological complexity, we propose CisTransCell, a cell-conditioned multi-modal framework for single-cell perturbation prediction that augments each gene with two complementary priors: a regulatory-sequence prior that captures how the gene is controlled, and a coding-sequence prior that captures what the gene product does. By integrating these priors with cellular expression state, CisTransCell models perturbation response as a cascade from gene function to regulatory control to downstream transcriptional change. Experiments on benchmark single-cell perturbation datasets show that CisTransCell achieves strong performance in zero-shot perturbation prediction.

04.
arXiv (CS.AI) 2026-06-19

Bidirectional Tutoring for Developmental Motor Learning in Robots: Co-Developed Interaction Dynamics Support Stable Learning

arXiv:2606.19728v1 Announce Type: cross Abstract: Infants are well known to develop their motor skills through dense interaction with caregivers. Although such social interaction is crucial for human development, motor-skill learning in robots is often treated as a unidirectional process in which robots passively receive demonstrations from tutors. This overlooks a key property of social interaction: it is inherently bidirectional, with tutor and learner dynamically adapting to each other. In such interactions, the robot's past experiences may function as prior constraints that shape the dynamics of their co-developed trajectories. We hypothesize that bidirectional tutoring allows such constraints to guide the formation of consistent behavioral patterns that preserve behavioral coherence and support generalization, whereas unidirectional interaction lacks such constraints and leads to broader, less consistent behavioral patterns. To examine this hypothesis, we conducted two experiments with a physical humanoid robot performing an object manipulation task: one involving human-robot interaction and another employing an AI tutor interacting with the real robot through an adaptive intervention mechanism designed to examine whether similar effects would emerge under more controlled conditions. We implement the developmental learning framework using a free-energy-principle-based neural network extended with generative replay, which supports stable sequence-by-sequence learning from single tutored episodes. Across both settings, bidirectional tutoring fostered consistent behaviors and stage-wise generalization, while the robot gradually required less tutor guidance. These results suggest that bidirectional tutoring, as an embodied and socially grounded approach, provides an effective scaffold for developmental motor learning in robots.

05.
arXiv (math.PR) 2026-06-17

Decay of correlations and zeros for the hard-core model

arXiv:2603.17858v2 Announce Type: replace Abstract: In a recent paper the last author proved that absence of complex zeros of the partition function of the hard-core model near a parameter $\lambda>0$ implies a form of correlation decay called strong spacial mixing. In this paper we investigate the reverse implication. We introduce a strengthening of strong spatial mixing that we call very strong spatial mixing (VSSM). Our main result is that if VSSM holds at a parameter $\lambda>0$ for a family of graphs, this implies that the partition function has no zeros near that parameter for each graph in the family. We also demonstrate that a closely related variant of very strong spatial mixing does not imply zero-freeness. As a consequence of our main result, we moreover obtain that VSSM implies spectral independence. Our proof relies on transforming the problem to the analysis of an induced non-autonomous dynamical system given by Möbius transformations.

06.
arXiv (math.PR) 2026-06-15

Sharp Favard length of random Cantor sets

arXiv:2512.17753v2 Announce Type: replace-cross Abstract: We show that for a large class of planar $1$-dimensional random fractals $S$, the Favard length $\operatorname{Fav}(S(r))$ of the neighborhood $S(r)$ is comparable to $\log^{-1}(1/r)$, matching a universal lower bound; up to now, this was only known in expectation for a few concrete models. In particular, we show that there exist $1$-Ahlfors regular sets with the fastest possible Favard length decay. For a wide class of planar one-dimensional "grid random fractals", including fractal percolation and its Ahlfors-regular variants, we further show that $\operatorname{Fav}(S(r))/\log(1/r)$ converges almost surely, and we identify the limit explicitly. Furthermore, we prove that for some $1$-dimensional Ahlfors-regular random fractals $S$, the Favard length of $S(r)$ decays instead like $\log\log(1/r)/\log(1/r)$, showing that the $1/\log(1/r)$ decay is not universal among random fractals, as might be expected from previous results.

07.
arXiv (quant-ph) 2026-06-24

Faster algorithm for achieving minimal-size quantum decision diagrams

arXiv:2606.24789v1 Announce Type: new Abstract: The decision diagram (DD) data structure enables fast linear-algebra calculations by bringing vectors into a normal form and subsequently merging equivalent ones, yielding a minimally-sized DD modulo the equivalence relation. A fruitful application area is quantum-circuit simulation, where the vectors represent quantum states. The Local Invertible Map Decision Diagram (LIMDD) type, merges LIM-equivalent (typically Pauli-gate equivalent) vectors, can efficiently simulate Clifford circuits as well as some high-T-count circuits, and has theoretically been proven exponentially faster for simulation than other well-developed data structures, including other common DD variants. However, these exponential advantages have not fully materialized yet in existing implementations, for which the normal-form procedure, which is a highly complex algorithm, is either absent or only partially implemented. We here present a novel normal-form algorithm for Pauli-LIMDDs, achieving a worst-case speedup from $O(n^3)$ to $O(n^2)$ for an $n$-qubit DD node with a single child node while keeping the $O(n^3)$ run time in case of two distinct children nodes. We implement the algorithm as part of QolDDer, our Pauli-LIMDD simulator for quantum circuits, written from scratch in C/C++. The implementation realizes the theoretically-proven advantages of Pauli-LIMDDs on Clifford circuits, is significantly faster than the existing LIMDD simulators on such circuits, and on a public quantum-circuit data set often outperforms them by an order of magnitude. In the future, we envision that our work will enable further application and development of LIMDD variants, not only for quantum design tasks, but also for analysis of linear-algebra-based systems in general.

08.
arXiv (CS.CL) 2026-06-12

Operads for compositional reasoning in LLMs

Question decomposition, i.e. breaking a complex query into simpler sub-queries whose answers are composed to produce a final answer, is a widely used strategy for improving LLM reasoning, yet it currently lacks a rigorous mathematical foundation. In this paper, we propose operads, mathematical structures that model many-in, one-out operations and compositions thereof, as a natural framework for describing question decomposition. We define the questions operad $Q$, in which operations correspond to question templates and composition corresponds to substitution of sub-answers, and show how QA models can be interpreted as algebras over $Q$. Beyond reframing existing practice, this operadic perspective points toward new methods, in particular a notion of operadic consistency, which measures whether a QA model's answers agree across the partial collapses of a question decomposition tree. Empirical evaluation of operadic consistency is reported in our companion paper (Bottman, Liu, and Richardson, 2026), which finds it strongly correlated with accuracy across twelve LLMs and four multi-hop QA datasets and outperforming standard temperature-based self-consistency baselines. We argue that operads are the natural mathematical home for question decomposition, and that invariants such as operadic consistency open new directions for analyzing and improving the reliability of multi-step reasoning.

09.
medRxiv (Medicine) 2026-06-12

Association of circulating endothelial progenitor cell count and functional outcome in patients with acute ischemic stroke due to intracranial large vessel occlusion

Background: Circulating endothelial progenitor cells (cEPCs) contribute to vascular repair following an ischemic stroke. The aim of the study was to evaluate the association between cEPCs and functional outcomes in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) who received endovascular therapy (EVT). Methods: Prospective study of patients with LVO-AIS who received EVT. Blood samples were obtained within 24 +- 12 hours and on day 7+-1 from stroke onset. cEPCs were detected using flow cytometry (CD34+/VEGFR2+/CD133+). The primary endpoint was a favourable functional outcome (modified Rankin Scale 0-2) at three months of follow-up. Secondary endpoints include baseline to 24 hours/day 7 changes in the National Institutes of Health Stroke Scale (NIHSS) score and collateral circulation (CC) status. Bivariate and multivariable logistic regression analyses were performed. Results: Included were 90 patients (73.2+-12.7 years, 41.1% women) in 42 of whom (46.7%) cEPCs were detected at 24 hours. On day 7, cEPCs were detected in 27 (43.6%) of 62 patients for which this information was available. Atrial fibrillation, prior anticoagulant treatment and stroke onset-to-door time

11.
arXiv (CS.CL) 2026-06-24

Paying to Know: Micro-Transaction Markets for Verified Product Information in Agentic E-Commerce

Commercial NLP treats the shopping chatbot as a recommender or a conversion tool: its job is to match a user to a catalogue entry and close a sale. We argue that the arrival of agent-native micro-payment rails (e.g., x402, AP2) changes what is scarce. When the buyer is an autonomous agent that can investigate exhaustively, the bottleneck is no longer matching products but acquiring trustworthy, decision-relevant information about them. We envision agentic e-commerce as a micro-transaction market for verified information: buyer agents spend fractions of a cent to progressively unlock seller- and reviewer-supplied data – service histories, third-party test reports, bills of materials, audited sales and support metrics – paid for a la carte under a freemium model, with reviewer trust scored reputationally. We sketch the architecture of such a market and argue that it rewards genuine product quality and yields truer competition than ranking-based storefronts. We then translate the vision into concrete NLP problems – cost-optimal information acquisition, data pricing and negotiation, real-time entity resolution, grounded value exchange, and privacy-preserving persona modelling – and argue that these, not chat fluency, deserve the field's attention.

12.
PLOS Computational Biology 2026-06-09

Evolution of phenocopying in a dynamical model of developmental trajectories

by Yuuki Matsushita, Archishman Raju Developmental trajectories are known to be canalized, or robust to both environmental and genetic perturbations. However, even when these trajectories are decanalized by an environmental perturbation outside the range of conditions to which they are robust, they often produce phenotypes similar to known mutants, called phenocopies. This correspondence between the effects of environmental and genetic perturbations has received little theoretical attention. Here, we study an abstract regulatory model that is evolved to follow a specific trajectory. We then study the effects of small and large perturbations to the trajectory, both by changing parameters and by perturbing the state at specific times. We find that the phenomenon of phenocopying emerges in evolved trajectories and is not present in a null model of randomly sampled trajectories. Our results suggest that, in this class of dynamic models, evolution can allow high-dimensional phenotypic landscapes to simultaneously exhibit robustness and phenocopying.

13.
arXiv (CS.AI) 2026-06-16

When Generator Replay Degrades: Projected Rehearsal Orchestration for Heterogeneous Federated Class-Incremental Learning

arXiv:2606.15695v1 Announce Type: cross Abstract: Federated class-incremental learning (FCIL) becomes substantially harder when clients observe different label subsets, progress through tasks at different stages, and provide uneven supervision for the same semantic concepts. Existing FCIL methods often preserve old knowledge through input-space synthesis, but they can be fragile under heterogeneous task streams and difficult to transfer across modalities. To alleviate such issues, we propose PRO, a framework that replaces synthetic input replay with projected rehearsal orchestration. To remove external pretraining, we evaluate all methods under the same warmup. After this, PRO maintains compact class-level projected memories on the server and allows clients perform balanced pseudo multi-task training over current examples and old projected memories. To handle stronger representation drift, we further introduce PRO-MAX, which augments PRO with neighborhood-weighted memory alignment while preserving the same server-light principle that the server only aggregates model updates and memory statistics. Across image, text, and graph benchmarks, PRO and PRO-MAX improve retention and final utility under heterogeneous streams while remaining competitive in homogeneous FCIL. Even when baselines are given expanded replay budgets, they degrade under supervision imbalance and stage misalignment, indicating that replay quantity alone does not resolve replay-quality failures. Additional weak-task diagnostics further show that larger replay mismatch is associated with larger downstream degradation, while our method keeps projected memories better aligned with the evolving representation.

14.
arXiv (CS.CV) 2026-06-24

Quantifying mandibular positioning error and simulated temporomandibular joint-space changes in patient-specific occlusal splints

Patient-specific occlusal positioning splints can be regarded as physical realisations of planned mandibular transformations. However, the achieved mandibular pose may differ from the planned one because of acquisition, registration, fabrication, and positioning errors. This study presents a transformation-based biomedical engineering framework for quantifying mandibular positioning accuracy and propagating the resulting error to a simulated temporomandibular joint configuration. Multimodal 3D data, including CBCT, facial motion acquisition, and dental scans, were integrated in a common coordinate system. Positioning splints corresponding to selected mandibular poses were designed and fabricated, and their realised positions were evaluated using repeated scans of plaster models. Discrepancies between planned and achieved positions were represented as rigid-body error transformations and analysed in SE(3), together with surface-distance metrics. The estimated transformations were propagated to CBCT-derived TMJ structures to quantify changes in condyle-fossa distance maps. The results demonstrate a systematic translational component and anisotropic variability of mandibular positioning error, with measurable propagation to simulated TMJ-space changes. The proposed framework provides an objective method for documenting planned and achieved mandibular configurations and for analysing positioning uncertainty in patient-specific splint workflows.

15.
arXiv (CS.CL) 2026-06-16

Evaluating the Robustness of Proof Autoformalization in Lean 4

Proof autoformalization aims to translate a mathematical informal proof written in natural language into a formal proof in a formal language such as Lean~4. Several works have developed LLM-based models for proof autoformalization. However, existing evaluations have typically focused on translating well-formed informal proofs from curated datasets. We argue that a robust proof autoformalizer must remain faithful even for informal proofs that diverge from these idealized ones, and we present the first study on the robustness of proof autoformalization models. We formulate two categories of perturbations and evaluate robustness under each: a global perturbation paraphrases the informal proof in a different style, under which the formalization should remain consistent; a local perturbation alters a value, symbol, or proof step, possibly in a counterfactual way, and a robust formalization should faithfully reflect the perturbation rather than reverting to the original one or inferring a different one on its own. We build a benchmark with both perturbations on miniF2F and MATH-500, and automatically measure how stable a proof autoformalization's correctness is under global perturbations and how faithfully its output reflects local perturbations. We evaluate seven recent models, all of which are sensitive to global perturbations and mostly fail to remain faithful under local perturbations. Code and data are available via https://github.com/ucr-rai/robust-proof-autoformalization.

16.
arXiv (CS.LG) 2026-06-24

A Robust Model-Based Approach for Continuous-Time Policy Evaluation with Unknown Lévy Process Dynamics

arXiv:2504.01482v3 Announce Type: replace-cross Abstract: This paper develops a model-based framework for continuous-time policy evaluation (CTPE) in reinforcement learning, incorporating both Brownian and Lévy noise to model stochastic dynamics influenced by rare and extreme events. Our approach formulates the policy evaluation problem as solving a partial integro-differential equation (PIDE) for the value function with unknown coefficients. A key challenge in this setting is accurately recovering the unknown coefficients in the stochastic dynamics, particularly when driven by Lévy processes with heavy tail effects. To address this, we propose a robust numerical approach that effectively handles both unbiased and censored trajectory datasets. This method combines maximum likelihood estimation with an iterative tail correction mechanism, improving the stability and accuracy of coefficient recovery. Additionally, we establish a theoretical bound for the policy evaluation error based on coefficient recovery error. Through numerical experiments, including a real-data BTC price experiment, we demonstrate the effectiveness and robustness of our method in recovering heavy-tailed Lévy dynamics and verify the theoretical error analysis in policy evaluation.

17.
arXiv (CS.AI) 2026-06-24

Offline Reinforcement Learning for Warehouse SLAM Throughput Control

arXiv:2606.23978v1 Announce Type: cross Abstract: We present an offline reinforcement learning (RL) framework for optimizing SLAM throughput control in a warehouse fulfillment environment. SLAM (Scan/Label/Apply/Manifest) throughput directly influences system congestion and operational efficiency. Our RL-based control approach dynamically recommends SLAM throughput settings that adaptively balance throughput maximization with downstream stability through intelligent adjustment of throttling behavior. We include a history-informed state representation, action space abstraction for delayed-impact control, and a reward function that captures both upstream and downstream operational metrics. Our approach is algorithm-agnostic, enabling integration of multiple offline RL methods under a unified architecture. We instantiate our framework with three state-of-the-art offline RL algorithms, and trained the models offline using de-identified historical operational logs from a large-scale warehouse. Policy performance is evaluated using a comprehensive multi-method strategy. These include model-free approaches including immediate reward estimation via regression models and long-horizon Fitted Q Evaluation (FQE), as well as model-based Deep Koopman dynamics evaluation. Empirical results reveal that the CQL policy consistently outperforms alternatives, improving system health by 22.97% and reducing average throttling duration by 3.18%. These findings demonstrate the potential of offline RL for safe and scalable warehouse throughput control optimization.

18.
arXiv (CS.CV) 2026-06-12

Allure of Craquelure: A Variational-Generative Approach to Crack Detection in Paintings

Recent advances in imaging technologies, deep learning and numerical performance have enabled non-invasive detailed analysis of artworks, supporting their documentation and conservation. In particular, automated detection of craquelure in digitized paintings is crucial for assessing degradation and guiding restoration, yet remains challenging due to the possibly complex scenery and the visual similarity between cracks and crack-like artistic features such as brush strokes or hair. We propose a hybrid approach that models crack detection as an inverse problem, decomposing an observed image into a crack-free painting and a crack component. A deep generative model is employed as powerful prior for the underlying artwork, while crack structures are captured using a Mumford–Shah-type variational functional together with a crack prior. Joint optimization yields a pixel-level map of crack localizations in the painting.

19.
arXiv (math.PR) 2026-06-11

Large deviations for marked sparse random graphs with applications to interacting diffusions

arXiv:2204.08789v2 Announce Type: replace Abstract: We consider the empirical neighborhood distribution of marked sparse Erdős-Rényi random graphs, obtained by decorating edges and vertices of a sparse Erdős-Rényi random graph with i.i.d. random elements taking values on Polish spaces. We prove that the empirical neighborhood distribution of this model satisfies a large deviation principle in the framework of local weak convergence. We rely on the concept of BC-entropy introduced by Delgosha and Anantharam~(2019) which is inspired on the previous work by Bordenave and Caputo~(2015). Our main technical contribution is an approximation result that allows one to pass from graph with marks in discrete spaces to marks in general Polish spaces. As an application of the results developed here, we prove a large deviation principle for interacting diffusions driven by gradient evolution and defined on top of sparse Erdős-Rényi random graphs. In particular, our results apply for the stochastic Kuramoto model. We obtain analogous results for the sparse uniform random graph with given number of edges.

20.
medRxiv (Medicine) 2026-06-23

Innate immunity associates with protection from pneumococcal colonisation, but colonisation does not confer capsule-independent protection

Nasopharyngeal colonisation with Streptococcus pneumoniae is a prerequisite for transmission and disease and represents an important immunising event. While colonisation induces serotype-specific immunity, the mechanisms underlying heterologous protection remain unclear. We developed a controlled human infection model using pneumococcal serotype 15B and investigated colonisation dynamics, immunogenicity, and cross-protection against subsequent heterologous challenge with serotype 6B. Fifty-four healthy adults were intranasally inoculated with 15B at escalating doses. Colonisation rates peaked at 31.4% with 8 x 10 CFU per naris, lower than those historically observed with 6B and 3 strains. Density was also lower than previously observed with other strains. In vitro assays demonstrated that 15B adhered more readily to epithelial cells than 6B, but was less efficiently internalised, potentially reducing attack rates and colonisation density. Colonisation with 15B induced capsular polysaccharide-specific serum IgG, but baseline humoral immune measures did not predict protection from acquisition. Prior colonisation with 15B did not reduce acquisition of 6B upon re-challenge. Analysis of nasal microbiopsy samples revealed distinct innate activation signatures. Resistance to colonisation was associated with elevated baseline MIP-1 and MIP-1{beta} responses upon in vitro stimulation, whereas carriage was associated with enhanced chemokine and IL-6 responses. Local innate immune activation, rather than circulating antibody responses alone, may therefore contribute to colonisation control. We demonstrate that experimental colonisation with 15B does not confer heterologous protection against 6B and highlight the importance of mucosal innate immune conditioning in serotype-independent defence. Strategies enhancing nasal innate immune recruitment and activation may be required for broader protection against pneumococcal colonisation.

21.
arXiv (CS.LG) 2026-06-19

Representing Piecewise-Linear Functions by Functions with Minimal Arity

arXiv:2406.02421v2 Announce Type: replace-cross Abstract: Any continuous piecewise-linear function $F\colon \mathbb{R}^{n}\to \mathbb{R}$ can be represented as a linear combination of $\max$ functions of at most $n+1$ affine-linear functions. In our previous paper [``Representing piecewise linear functions by functions with small arity'', AAECC, 2023], we showed that this upper bound of $n+1$ arguments is tight. In the present paper, we extend this result by establishing a correspondence between the function $F$ and the minimal number of arguments that are needed in any such decomposition. We show that the tessellation of the input space $\mathbb{R}^{n}$ induced by the function $F$ has a direct connection to the number of arguments in the $\max$ functions.

22.
arXiv (CS.CL) 2026-06-19

Displacement Is Not Direction: Evaluating Fidelity Metrics for Quantized LLM Deployment

Fidelity metrics, such as per-token KL divergence (KLD) against a high-precision reference, are often used in practice as low-cost proxies for benchmark quality. We test this practice on a 28-quant cohort of Qwen3.6-35B-A3B and a 41-quant cohort of Devstral-Small-2-24B, evaluated across a suite of downstream benchmarks. We find that KLD is strongly correlated with benchmark score over the full cohort ($\rho=-0.72$ on Qwen and $\rho=-0.86$ on Devstral, both with $p

23.
arXiv (CS.CL) 2026-06-12

An End-to-End Hybrid Framework for Rumour Detection in Low-Resources Algerian Dialect

The rapid growth of social media has intensified the spread of rumours. This issue is more challenging in the Algerian context due to the informal and code-switched nature of dialectal content, the scarcity of annotated resources, and the limited effectiveness of standard Arabic NLP tools on dialect text. This paper presents an end-to-end rumour detection hybrid framework for Algerian dialect social media content. We build a domain-specific annotated dataset by combining real social media posts, synthetic data, and the FASSILA corpus, with automatic labeling based on a similarity-based annotation process. A transliteration pipeline is also introduced to generate parallel datasets in Arabic script and Arabizi. We evaluate multiple approaches, including classical machine learning, deep learning, transformers, and hybrid models. Experimental results show that a hybrid approach combining transformer embeddings with a classical classifier achieves the best performance, reaching an F1-score of 0.84. We also find that domain-specific pre-training is more important than model size, with social media-trained models outperforming larger models trained on formal Arabic corpora. These results demonstrate the feasibility of rumour detection in low-resource Algerian dialect settings.

24.
medRxiv (Medicine) 2026-06-22

Starting, stopping and restarting. Patterns of Methylphenidate Use over 14 years in a large public health system

Background Persistence with stimulant medication is poor in children and adolescents with ADHD, and the evidence base is derived predominantly from high-income countries. We describe methylphenidate utilisation patterns and predictors of 12-month retention across 14 years in a large South African public health service. Methods Retrospective cohort study using routine pharmacy data from the Western Cape provincial health service (2011-2024). Children aged 5-18 at first prescription were included. Treatment episodes were defined as continuous prescription sequences with no gap exceeding 90 days and classified as initiations or restarts. Logistic regression modelled 12-month retention against early visit frequency and formulation type as pre-specified exposures. Findings 421,925 prescription events for 23,243 children across 115 facilities generated 65,885 treatment episodes. Median age at first prescription was 10 years (IQR 8-12); 77.6% were male. Kaplan-Meier 12-month survival was 28.2% for initiations and 15.4% for restarts, substantially below high-income country comparators. A quarter of all initiating prescriptions were not followed by a subsequent dispensing event; nearly 40% of patients had three or more treatment episodes. Early visit frequency was the strongest predictor of 12-month retention (high vs low: OR 2.85, 95% CI 2.65-3.06). The sustained-release formulation effect was present but attenuated on multivariable adjustment. Treatment re-initiations showed a marked seasonal pattern consistent with the South African school calendar. Interpretation Twelve-month retention was markedly lower than high-income country rates. Against a backdrop of high attrition, both early visit frequency and sustained-release formulation access predicted persistence; clinical engagement and reducing structural barriers to access are modifiable factors in this setting. Funding None.

25.
medRxiv (Medicine) 2026-06-15

ICD-10 Code Ambiguity Obscures Treatment-Eligible Adults with Spinal Muscular Atrophy: A Single-Center Chart Review and Patient Outreach Study

Background. Three disease-modifying therapies (DMTs) for spinal muscular atrophy (SMA) have been approved since 2016, yet many adults remain untreated. Identifying them depends on ICD-10 codes that capture SMA but do not reliably distinguish it from other related conditions. We examined, in one U.S. health system, both patients' engagement with therapy and the accuracy of the codes used to find them. Methods. We conducted a retrospective chart review of adults in an academic health system identified by SMA-associated ICD-10 codes, with manual adjudication of diagnosis and DMT status. Confirmed SMA-positive, DMT-naive patients were invited to a structured telephone interview on treatment awareness and barriers. Results. Of 60 charts, 22 (36.7%; 95% CI 25.6-49.3%) were appropriately coded for SMA or a related disorder; only 16 (26.7%) had molecularly confirmed SMA. The other 38 (63.3%) were miscoded, spanning spinal and bulbar muscular atrophy, asymptomatic carriers, prenatal screening, and conditions unrelated to SMA. Ten of the 16 confirmed patients (62.5%) were DMT-naive; one was interviewed, one declined, and eight could not be reached. The non-response is itself a finding: the patients least visible to administrative data are the hardest to reach. Conclusions. ICD-10 ambiguity is a barrier to treatment access in adult SMA, as is loss to follow-up. We make two recommendations: continuous documentation-coding alignment that uses natural language processing to verify the genetic precondition, and type-specific SMA codes (subcodes for Types 0-4) anchored on molecular SMN1 confirmation. Together these would support cohort identification, outreach, and evidence generation without adding to clinician burden.