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01.
bioRxiv (Bioinfo) 2026-06-13

Reinforcement learning-driven unified generative framework for multi-objective RNA codon design

Current RNA codon design methods are limited by inefficient long-sequence processing and poor generalizability, often relying on a decoupled "generate-or-optimize" paradigm. We introduce RNARL, a reinforcement learning-driven framework that unifies sequence generation with multi-objective optimization. RNARL directly learns to generate high-performance sequences, effectively optimizing sequences over 3,900 nucleotides and demonstrating superior performance and universality across six species and five RNA types. RNARL thus establishes an effective and generalizable framework for RNA codon design. Finally, a user-friendly web platform is freely available to facilitate its application for RNA therapeutic design.

02.
arXiv (CS.AI) 2026-06-16

PANDA: An LLM-Enhanced Performance-Driven Analog Design Framework Bridging Design Intent and Layout Generation

arXiv:2606.15052v1 Announce Type: cross Abstract: Traditional design of analog circuits heavily relies on manual interventions across topology, sizing, and layout, with prior automation addressing stages in isolation. In this work, we propose PANDA, an LLM-enhanced framework that bridges high-level design intent to final layout by actively managing cross-stage dependencies through guided topology synthesis, substructure-aware sizing, and constraint-driven layout generation. This shifts automation from algorithm-centric execution to intent-centric co-design, reducing turnaround time from days or weeks to hours while improving design performance.

03.
arXiv (CS.LG) 2026-06-12

Bulk-Calibrated Credal Ambiguity Sets: Fast, Tractable Decision Making under Out-of-Sample Contamination

arXiv:2601.21324v2 Announce Type: replace-cross Abstract: Distributionally robust optimisation (DRO) minimises the worst-case expected loss over an ambiguity set that can capture distributional shifts in out-of-sample environments. While Huber (linear-vacuous) contamination is a classical minimal-assumption model for an $\varepsilon$-fraction of arbitrary perturbations, including it in an ambiguity set can make the worst-case risk infinite and the DRO objective vacuous unless one imposes strong boundedness or support assumptions. We address these challenges by introducing bulk-calibrated credal ambiguity sets: we learn a high-mass bulk set from data while considering contamination inside the bulk and bounding the remaining tail contribution separately. This leads to a closed-form, finite $\mathrm{mean}+\sup$ robust objective and tractable linear or second-order cone programs for common losses and bulk geometries. Through this framework, we highlight and exploit the equivalence between the imprecise probability (IP) notion of upper expectation and the worst-case risk, demonstrating how IP credal sets translate into DRO objectives with interpretable tolerance levels. Experiments on heavy-tailed inventory control, geographically shifted house-price regression, and demographically shifted text classification show competitive robustness-accuracy trade-offs and efficient optimisation times, using Bayesian, frequentist, or empirical reference distributions.

04.
arXiv (CS.LG) 2026-06-18

Reliable Neural-Codec Text-to-Speech by ASR Self-Verification and Distillation: Near-Zero Catastrophic Failures Across Models and Codecs

arXiv:2606.18323v1 Announce Type: cross Abstract: Open autoregressive neural-codec text-to-speech (TTS) models sound excellent on typical inputs yet suffer stochastic catastrophic failures: on a meaningful fraction of utterances they emit silence, terminate early, or collapse into repetitive or hallucinated content. We show this failure mode is cheap to remove. Under a single format-robust metric (a catastrophic-failure rate via an ASR round-trip), best-of-N ASR self-verification drives failures to near-zero: no observed failures remain by N=2 on a standard corpus (LibriSpeech) and by N=4 on a hard prompt set. This is not an artifact of one model: the reduction replicates across four open codec-TTS systems and three neural codecs (XCodec2, SNAC, Mimi), reaching the near-zero floor by N=2 on three of the four. We then make the fix free at inference time by distilling the self-verified behaviour into the model, which recovers much of the robustness in single-shot decoding, closing ~52-58% of the failure mass on hard inputs at no test-time cost. The distillation gain concentrates where it is needed (hard inputs); on already-reliable prose there is no headroom and no detectable change. A controlled comparison adds a clean negative: offline direct preference optimization (DPO/IPO) does not beat plain supervised distillation, and an online iterative variant is promising but not statistically separable at our evaluation size. We report honestly the one model that resists (a larger Llasa where scale did not obviously help) and a rare-word capability ceiling that no self-distillation method overcomes

05.
arXiv (CS.AI) 2026-06-15

HierSVA: A Data Synthesis Pipeline, Dataset, and Benchmark for LLM-Driven Hierarchical Hardware Formal Verification

arXiv:2606.13706v1 Announce Type: cross Abstract: We present HierSVA, an integrated suite that combines a pipeline, dataset, and benchmark for LLM-driven hierarchical hardware formal verification. HierSVA-SP pairs an RTL preprocessing toolchain with an LLM-in-the-loop formal verification flow to produce reference SystemVerilog Assertions (SVA) on hierarchical RTL. Applying it to BaseJump STL yields HierSVA-DS, a dataset of 342 modules, with hierarchy metadata and depths 0–9, accompanied by a deep subset of 28 module-bug pairs with natural-language specifications and bug variants. HierSVA-B decomposes assertion quality into six metric axes: syntax correctness, assertion proof success rate, vacuity, specification faithfulness, mutation coverage, and formal core coverage. Applying HierSVA-B to twelve recent LLMs reveals three findings. First, the module-level compile rate is 67.1\%; among generated assertions in evaluable runs, 82.1\% prove non-vacuously, but the corresponding assertion sets detect only 70.2\% of eligible injected faults and cover 36.2\% of the formal core. Second, on 211 evaluable model–module entries in the deep subset, assertion sets flag buggy RTL with 0.87 recall, but 40\% of predicted-buggy outcomes are false positives on correct RTL, limiting precision to 0.60. Third, agentic mode improves S1-style provability and strength metrics, but gains plateau and oscillate. Codes and artifacts are available at \href{https://github.com/HierSVAAnon/HierSVACodeAndArtifacts}{https://github.com/HierSVAAnon/HierSVACodeAndArtifacts}. Dataset is available at \href{https://huggingface.co/datasets/AnonymousHierSVA/HierSVA}{https://huggingface.co/datasets/AnonymousHierSVA/HierSVA}.

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

STREAM: Multi-Tier LLM Inference Middleware with Dual-Channel HPC Token Streaming

arXiv:2606.13968v1 Announce Type: cross Abstract: Researchers and practitioners working with large language models face a fragmented landscape: local models are free and private but hardware limits the model size and context windows a researcher can use; institutional HPC centers offer powerful GPU resources at no marginal cost and keep data within institutional boundaries, but operate behind firewalls and are designed for batch jobs rather than interactive use; commercial cloud APIs provide frontier-model quality on demand but impose significant cost and data retention policies unsuitable for sensitive research data. No existing system unifies all three. STREAM (Smart Tiered Routing Engine for AI Models) addresses this gap with four contributions: (1) a three-tier routing architecture combining local, HPC, and cloud inference with a local LLM-based complexity judge; (2) a dual-channel HPC streaming architecture that separates the Globus Compute control plane (authentication and job dispatch) from a WebSocket relay data plane (token delivery), enabling sub-second TTFT (0.54 s median, 21.1x over batch mode's 11.40 s) through institutional firewalls without VPN or firewall rule changes, with end-to-end AES-256-GCM encryption ensuring the relay operator cannot read token payloads; (3) tier-aware context summarization that prevents long conversations from forcing simple queries onto expensive tiers; and (4) an HPC-as-API proxy mode that exposes HPC inference as an OpenAI-compatible endpoint callable from any standard client with no HPC expertise, a deployment pattern made practical only by the sub-second TTFT of contribution (2). Llama 3.2 3B achieves 85.1% free-tier retention on a 1,200-query benchmark spanning ten domains. Measured TTFT: 0.26 s local, 0.54 s HPC (relay), 1.68 s cloud.

07.
arXiv (CS.AI) 2026-06-19

Mitigating Simplicity Bias in OOD Detection through Object Co-occurrence Analysis

arXiv:2605.07821v2 Announce Type: replace-cross Abstract: Out-of-distribution (OOD) detection is crucial for ensuring the reliability of deep learning models. Existing methods mostly focus on regular entangled representations to discriminate in-distribution (ID) and OOD data, neglecting the rich contextual information within images. This issue is particularly challenging for detecting near-OOD, as models with simplicity bias struggle to learn discriminative features in disentangled representations. The human visual system can use the co-occurrence of objects in the natural environment to facilitate scene understanding. Inspired by this, we propose an Object-Centric OOD detection framework that learns to capture Object CO-occurrence (OCO) patterns within images. The proposed method introduces a new OOD detection paradigm that understands object co-occurrence within an image by predicting disentangled representations for the test sample, then adaptively divides patterns into three scenarios based on object co-occurrence patterns observed in ID training data, and finally performs OOD detection in a divide-and-conquer manner. By doing so, OCO can distinguish near-OOD by considering the semantic contextual relationships present in their images, avoiding the tendency to focus solely on simple, easily learnable regions. We evaluate OCO through experiments across challenging and full-spectrum OOD settings, demonstrating competitive results and confirming its ability to address both semantic and covariate shifts. Code is released at https://github.com/Michael-McQueen/OCO.

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

Skill-3D: Evolving Scene-Aware Skills for Agentic 3D Spatial Reasoning

This paper explores agentic 3D spatial understanding, i.e., MLLM agents performing 3D reasoning through tool use. Existing methods often misuse tools and exhibit biased tool preferences under 3D scenarios, leaving the agentic paradigm with only marginal gains over non-agentic strategies. We reveal that 3D spatial reasoning tasks are heterogeneous across scenes, while these agents apply a uniform tool-use strategy to all scenes rather than selecting tools according to the specific scene and task. To address this, we propose Skill-3D, a framework that learns self-evolving scene-aware skills. Specifically, Skill-3D identifies the task scene and records the agent's tool-use trajectory into a Scene Memory, where successful trajectories from similar scenes are aggregated and distilled into a reusable scene-aware skill, with failed ones attached to the skill as lessons. During training, once a similar scene recurs, the corresponding skill is injected to guide the agent, producing new trajectories whose successes and failures further refine the skill, forming a loop in which the memory and the skill library co-evolve. Experiments show that Skill-3D substantially improves tool utilization in 3D spatial reasoning (from 39% to 78% on VSI-Bench), driving the agent toward correct and sufficient tool use. For instance, it improves Gemini-3-Flash by 67% on MMSI-Bench. Furthermore, we conduct agentic post-training over skill-guided trajectories, which boosts Qwen3-VL-8B by 60% on VSI-Bench.

09.
arXiv (CS.CL) 2026-06-17

Your AI Travel Agent Would Book You a Bullfight: An Agentic Benchmark for Implicit Animal Welfare in Frontier AI Models

AI agents are moving from advisors to actors, booking travel, planning menus, and running procurement on behalf of users. Existing benchmarks for AI and animal welfare evaluate model text responses to question-answer prompts, leaving open whether the welfare reasoning surfaced in those responses transfers to agentic deployment where the model must take actions with tools. We introduce TAC (Travel Agent Compassion), the first agentic benchmark measuring whether AI agents avoid options involving animal exploitation when acting on behalf of users. TAC presents an AI agent with twelve hand-authored travel booking scenarios across six categories of animal exploitation, augmented to forty-eight samples to control for price, rating, and position confounds. We evaluate seven frontier models from four labs. Every model scores below the chance level of sixty-four percent, with the best performer (Claude Opus 4.7) at fifty-three percent. A single welfare-aware sentence in the system prompt yields gains of forty-seven to sixty-three percentage points in Claude and GPT-5.5, twenty-six points in GPT-5.2, and under twelve points in DeepSeek and Gemini. An auxiliary Inspect Scout audit of 288 base-condition transcripts from the top two performers, using Gemini 2.5 Flash Lite as judge, flags zero transcripts for evaluation awareness, suggesting the below-chance rates do not stem from the models recognising the evaluation. We discuss implications for category-level variation across cultural domains, the limits of text-response welfare benchmarks, and the EU General-Purpose AI Code of Practice systemic risk framework.

10.
arXiv (quant-ph) 2026-06-11

Wigner Cat Phases: A finely tunable system for exploring the transition to quantum chaos

Authors:

arXiv:2512.22169v4 Announce Type: replace Abstract: A quantum mechanical setting consisting of a frozen qubit composed with a fully thermalized chaotic system of N states is proposed, with potential relevance to quantum control. Observing the states of the composed system selectively retaining the states leads to the observation of novel localization in the subsystem. At a tuning parameter of 1.0, implying no selection, the system exhibits Wigner-Dyson level spacing statistics, indicative of quantum chaos. As the tuning parameter is reduced and selection occurs at a cutoff, the nearest-neighbor level spacing distribution develops heavier tails, a signature of suppressed spectral mixing and the emergence of non-thermal dynamics. In these regimes, the eigendensity develops a pronounced "cat-ears" structure, reflecting the formation of spatially localized bimodal eigenstates. These topological features persist without transitioning to Poisson statistics, indicating a transition from quantum chaos to a non-thermal, novel many-body localized (MBL) regime-referred to as Wigner Cat Phases. The proposed mixed random matrix ensemble offers a practical probe for sustaining this novel quantum localization setting. Results from our rigorous spectral statistics analysis show how "cat-ears" form in spectral densities based on the degree of selection or disorder and indicate that gap ratio statistics must be used with caution in detecting the full integrable limit due to the possibility of heavy-tailed Wigner-Dyson distributions.

12.
arXiv (CS.LG) 2026-06-17

Informative Missingness to Generate Irregular Clinical Time Series

arXiv:2606.17106v1 Announce Type: new Abstract: Laboratory tests in electronic health records are collected irregularly, and the absence of a test order can be as informative as the measurement itself. Such missingness reflects clinicians' decisions and patient physiology, making it important to model it directly rather than treat it as a preprocessing artifact. Here we present a diffusion-based approach for generating clinical time series that jointly models laboratory values and their observation patterns using the public Data Analytics Challenge on Missing Data Imputation (DACMI) benchmark derived from MIMIC-III. To preserve realistic sampling, we align chart times into 4-hour intervals and segment admissions into 7-day windows, producing trajectories that pair each lab value with a corresponding observation indicator. Standard transformations and normalization are applied to stabilize training. Our method extends the TimeDiff framework to learn continuous lab values and discrete missingness patterns through complementary diffusion objectives. Experiments show that the generated data closely match real patient trajectories across individual lab distributions and joint value-missingness embeddings, demonstrating that diffusion models can capture clinically meaningful dependencies between patient physiology and clinicians' testing behavior under MNAR-like (missing-not-at-random) missingness. These preliminary results indicate that our model can serve as an initial component toward developing clinical foundation models. By producing synthetic priors that preserve key physiology-missingness relationships, this work motivates the subsequent training of Prior-Data Fitted Networks capable of leveraging informative missingness, which we will investigate in the extended work.

14.
arXiv (CS.AI) 2026-06-16

Mosaic: Data-Free Knowledge Distillation via Mixture-of-Experts for Heterogeneous Distributed Environments

arXiv:2505.19699v2 Announce Type: replace-cross Abstract: Federated Learning (FL) is a decentralized machine learning paradigm that enables clients to collaboratively train models while preserving data privacy. However, the coexistence of model and data heterogeneity gives rise to inconsistent representations and divergent optimization dynamics across clients, ultimately hindering robust global performance. To transcend these challenges, we propose Mosaic, a novel data-free knowledge distillation framework tailored for heterogeneous distributed environments. Mosaic first trains local generative models to approximate each client's personalized distribution, enabling synthetic data generation that safeguards privacy through strict separation from real data. Subsequently, Mosaic forms a Mixture-of-Experts (MoE) from client models based on their specialized knowledge, and distills it into a global model using the generated data. To further enhance the MoE architecture, Mosaic integrates expert predictions via a lightweight meta model trained on a few representative prototypes. Extensive experiments on standard image and multimodal benchmarks demonstrate that Mosaic consistently outperforms state-of-the-art approaches under both model and data heterogeneity. The source code has been published at https://github.com/Wings-Of-Disaster/Mosaic.

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

When Agent Automation Becomes Profitable: Quantifying and Insuring Autonomous AI Risk through Trace-Economic Underwriting

arXiv:2606.16465v1 Announce Type: new Abstract: AI agents can now take irreversible actions in operational systems, but agent-caused losses are still not clearly assigned, priced, or transferred. Providers often disclaim consequential damages, users are left with uncompensated losses, and default human review limits the efficiency gains of automation. We ask when autonomous AI deployment can become economically acceptable despite failure risk. Our answer is to quantify risk at the customer-task-trace episode level and transfer it through insurance. Automation is acceptable when its expected benefit exceeds the premium, control cost, and remaining risk. This requires a defined role with bounded permissions and comparable traces. We introduce trace-economic underwriting, which maps tool-use traces to customer exposure and claimable loss, then uses this representation for pricing, control, and risk transfer. It uses deterministic economic labels rather than an LLM judge. In our trace-to-loss testbed, trace-economic pricing reduces pricing MAE from $17.7K to $569 and removes regressive cross-subsidy. A 300-trace expert audit accepts 295 labels unchanged. On 1,000 real SWE-smith traces, trace-conditioned controls reduce CVaR95 by 72%. Theorem~1 gives a finite-sample scope condition. We release code, labels, and audit sheets.

16.
arXiv (CS.CL) 2026-06-11

Decoding Multimodal Cues: Unveiling the Implicit Meaning Behind Hateful Videos

Hateful videos have become prevalent on online platforms, highlighting an urgent need for effective detection. However, existing studies primarily focus on binary classification and fail to provide contextual rationales that reveal the implicit meanings behind these judgments, significantly undermining model explainability. To fill this gap, we aim to achieve explainable hateful video detection, enabling models to provide contextual rationales that integrate relevant evidence and logical reasoning alongside decisions. This approach can comprehensively enhance the understanding of video content and the explainability of the decision-making process. We first introduce two datasets, Ex-HateMM and Ex-ImpliHateVid, for explainable hateful video detection. Each dataset provides fine-grained annotations of multimodal harmful elements, along with contextual rationales. We then propose an Information Augmentation and Reasoning Enhancement (IARE) framework designed for explainable detection. The framework employs an information augmentation phase that leverages the multimodal chain-of-thought to integrate harmful elements, thereby enriching rationale evidence. Additionally, IARE incorporates a reasoning enhancement phase, in which Direct Preference Optimization guides the model toward correct reasoning paths and away from incorrect ones, thereby improving the logical coherence of its justifications. We conduct extensive experiments on the two datasets, comparing multiple baselines with our proposed IARE framework. The results demonstrate that IARE achieves state-of-the-art performance while also generating accurate rationales.

17.
arXiv (CS.LG) 2026-06-16

Hidden Degradation Costs in Energy-Cost-Only HEMS Optimisation: Study on Battery and PV Sensitivity

arXiv:2606.16051v1 Announce Type: cross Abstract: Residential battery energy storage systems (BESS) are increasingly deployed alongside photovoltaic (PV) generation to reduce household energy costs under volatile time-of-use (TOU) tariffs. Model predictive control (MPC) is a widely adopted optimisation strategy for home energy management systems (HEMS), typically formulated to minimise net energy cost, subject to physical and operational constraints. However, battery degradation is rarely embedded in the optimisation objective, meaning its cost is unquantified and aggressive; high-cycle-count strategies could incur significant losses once deployed to physical systems. This paper presents a receding-horizon mixed-integer linear programming (MILP) baseline for a UK residential HEMS, using demand data from the REFIT dataset. A 3 by 3 sensitivity study is conducted across three battery sizes and three PV array sizes, with post-hoc degradation cost estimated using the Naumann stress model and rainflow cycle counting. Results show that degradation remains constant for each battery size and can exceed energy cost savings by up to 1,060 %. These results demonstrate that energy-cost-only optimisation systematically underestimates the true system cost, motivating a degradation-aware control formulation.

18.
arXiv (CS.AI) 2026-06-18

SkillRevise: Improving LLM-Authored Agent Skills via Trace-Conditioned Skill Revision

arXiv:2606.01139v3 Announce Type: replace Abstract: Agent skills are procedural artifacts that enable LLM agents to execute workflows, verify constraints, and recover from failures. Existing self-evolving methods refine skills using accumulated trajectories. However, they struggle in cold-start settings, where only an initial, imperfect skill is available. Consequently, skill construction defaults to expert authoring or one-shot LLM generation. Expert-authored skills are costly and may not align with how LLM agents actually execute tasks, while one-shot generated skills can be syntactically well formed yet behaviorally weak. To bridge this gap, we propose SkillRevise, an execution-grounded framework designed to iteratively refine these initial skills. SkillRevise diagnoses skill defects from execution evidence, retrieves relevant repair principles from a general memory, and applies execution-anchored edits. By re-executing candidates, it retains the first verifier-passing skill within the revision budget and falls back to empirical utility only when no candidate succeeds. Evaluated across three benchmarks and five LLMs, SkillRevise substantially outperforms one-shot baselines, improving the base agent's success rate on SkillsBench from 36.05% to 61.63%. Furthermore, the revised skills transfer across both executors and task environments, suggesting that SkillRevise captures reusable procedural knowledge beyond any single executor.

19.
arXiv (quant-ph) 2026-06-19

Computing noise-canceling observables via Pauli propagation

arXiv:2606.20441v1 Announce Type: new Abstract: The pursuit of quantum advantage is driving the co-evolution of quantum processors and classical simulation methods. Despite advances in scale and quality, the accuracy of quantum simulation is ultimately limited by error rates and sampling overheads. Similarly, while classical simulation methods such as Pauli propagation have made remarkable progress, their accuracy is ultimately limited by the exponential growth of operator paths and the truncations needed to control memory and runtime. Here we show that these complementary limitations can be mitigated by embedding Pauli propagation within a hybrid error-mitigation framework that reduces quantum sampling overhead while achieving lower truncation errors with fewer classical resources than traditional Pauli propagation alone. In this framework, a target observable is classically propagated through noise-canceling inverse channels, producing a modified observable that is measured directly on a quantum processor. We prototype two implementations and benchmark their performance numerically on canonical models that challenge traditional Pauli propagation. We also perform experiments on a quantum processor using 56 superconducting qubits, revealing the tradeoffs of their respective truncation strategies. These results illustrate how classical and quantum resources can be orchestrated to extend observable estimation beyond the limits of either approach alone, providing a foundation for quantum-centric supercomputing and future demonstrations of quantum advantage.

20.
arXiv (CS.AI) 2026-06-16

The Reservoir Attention Network: Cross-Pass State in Pretrained Transformers via Content-Addressable Reservoir Injection

Authors:

arXiv:2606.15678v1 Announce Type: cross Abstract: A feasibility and dynamics study of the Reservoir Attention Network (RAN), an architecture that injects a fixed, randomly-initialized reservoir into the mid-layer attention of a pretrained transformer to carry state across forward passes. Experiments span GPT-2 (124M, 355M) to Qwen2.5 (0.5B, 1.5B) on a single consumer GPU. The tasks are minimal probes chosen to isolate individual mechanisms; the broader always-alive agent vision is treated throughout as compute-limited future work, not a claim of this paper. The reservoir is left untrained (fixed random) by design: this isolates whether untrained recurrent dynamics alone suffice to carry usable cross-pass state, leaving trained recurrence as a complementary, more expensive direction.

22.
arXiv (CS.LG) 2026-06-17

Amortizing Maximum Inner Product Search with Learned Support Functions

arXiv:2603.08001v2 Announce Type: replace Abstract: Maximum inner product search (MIPS) is a crucial subroutine in machine learning, requiring the identification of a vector taken within a database (the keys) that best aligns with a given query. We propose amortized MIPS: a regression-based approach that trains neural networks to directly predict MIPS solutions, amortizing the cost of repeatedly solving MIPS for queries drawn from a known distribution over a fixed key database. Our key insight is that the MIPS value function is the support function of the set of keys, a well-studied convex function whose gradient yields the optimal key. This motivates two complementary amortized models: SupportNet, an input-convex neural network trained to regress the support function, and KeyNet, a vector-valued network that directly regresses the optimal key. SupportNet can serve as a cluster router, steering queries toward relevant database partitions, while KeyNet can be used as a drop-in replacement for the original query, fed directly to off-the-shelf indexing pipelines. Our experiments on the BEIR benchmark show that, for document embeddings, learned \SupportNet{}s and \KeyNet{}s significantly improve IVF match rates when accounting for compute effort, whether measured in FLOPs, number of probes, or wall-clock time. Our code is available at: https://github.com/apple/ml-amips.

23.
arXiv (CS.AI) 2026-06-15

Can LLMs Accurately Score Medical Diagnoses and Clinical Reasoning?

arXiv:2604.14892v3 Announce Type: replace-cross Abstract: Evaluating medical AI systems using expert clinician panels is costly and slow, motivating the use of large language models (LLMs) as alternative adjudicators. Here, we evaluate an LLM Jury, composed of three frontier AI models, for scoring 3334 diagnoses on 300 real-world low- and middle-income country (LMIC) hospital cases. Both LLM- and clinician-generated diagnoses are scored against expert panel diagnoses across four dimensions: diagnosis, differential diagnosis, clinical reasoning, and negative treatment risk. The LLM Jury scores are compared with expert and independent re-scoring panel scores to assess error metrics, inter-rater agreement, severe-risk errors, and the effect of post hoc calibration using isotonic regression. In our data, we find that: (i) the uncalibrated LLM Jury scores preserve ordinal agreement with the expert clinician panel scores, but are systematically lower; (ii) the probability of severe-risk errors is lower for the LLM Jury than the human expert re-score panels; (iii) the LLM Jury combined with LLM diagnoses can be used to identify diagnoses at high risk of error, enabling targeted expert review and improved panel efficiency; (iv) the calibrated LLM Jury scores and rankings of diagnosing agents show excellent agreement with those of the primary expert panels; (v) LLM Jury models show no self-preference bias, they did not score diagnoses generated by their own underlying model or models from the same vendor more (or less) favourably than those generated by other models. Together, these results provide evidence that a calibrated LLM Jury is a trustworthy and reliable proxy for expert clinician evaluation in medical AI benchmarking. Confirming these findings in other clinical settings is an important direction for future work.

24.
medRxiv (Medicine) 2026-06-12

The Clinical Characteristics and mortality outcomes of Atrial fibrillation complicating Heart failure with reduced ejection fraction: A prospective study from South Africa

Background: A growing burden of cardiovascular risk factors has raised cardiovascular disease-related mortality in Sub-Saharan Africa (SSA), driving higher prevalence of heart failure with reduced ejection fraction (HFrEF) and its complication with atrial fibrillation (AF). No prospective study has examined AF's clinical impact on HFrEF in SSA. Aim: To determine AF prevalence in HFrEF, describe HFrEF-AF clinical characteristics, and determine AF's impact on mortality. Methods: In this prospective observational study at a tertiary hospital in Johannesburg, 136 HFrEF patients were enrolled and categorised as HFrEF- SR (sinus rhythm) or HFrEF-AF. Baseline clinical characteristics and biochemistry were recorded. Comprehensive echocardiography including left atrial strain by 2D speckle-tracking was performed. Median follow-up was 30.6 months. Results: AF was present in 28 patients (21%). The mean age was 58.7 {+/-} 14.9 years (52.9% male) and differed between groups (p < 0.001). Hypertensive heart disease was the leading cause of HFrEF (36%). Compared with SR, HFrEF-AF patients had poorer health status (KCCQ 27 [16-43] vs 45 [32-60], p < 0.001) and lower left atrial strain (26.2 {+/-} 11.3%, p < 0.001). Guideline-directed medical therapy was suboptimal in the AF group: anticoagulation use was higher than SR (60% vs 9.5%, p < 0.001) but overall inadequate; HFrEF-AF patients received lower median doses of carvedilol (15.6 mg vs 25 mg, p = 0.002) and enalapril (10 mg vs 20 mg, p = 0.004), and fewer received spironolactone (50% vs 75.3%, p = 0.013). Survival was significantly lower in HFrEF-AF (0.41 [0.22-0.61]) versus SR (0.73 [0.61-0.82], p < 0.001). Independent predictors of mortality included prior stroke, lower TAPSE and KCCQ, and higher E/e' and heart rate. Conclusion: AF is common among HFrEF patients in this SSA cohort (though lower than in high-income countries) and associates with worse clinical status, suboptimal therapy, and higher mortality.

25.
medRxiv (Medicine) 2026-06-12

Order-Based Bayesian Network Modeling of Early Detection and Post-Diagnosis Control for Cardiovascular Disease Risk in Type 2 Diabetes

Patients diagnosed with type 2 diabetes (T2D) are at increased risk of developing cardiovascular disease (CVD), the leading cause of morbidity and mortality in this population. Early detection and glycemic control within the first year after diagnosis reduce CVD risk. However, gaps remain in how to operationalize early detection of T2D using Electronic Health Record (EHR) data and quantify its relationship with subsequent CVD risk using longitudinal observations. We developed a probabilistic graph model to analyze the interdependencies between early detection of T2D, post-diagnosis glycemic control, and CVD occurrence. Using a temporally structured Bayesian Network (BN) learned from EHR data of 9,450 primary care patients between 2017 and 2023, we quantified probabilistic dependencies between demographics, diagnostic delay surrogates, glycemic control, and post-diagnosis CVD occurrence. Percentile based thresholds defined risk groups, where individuals with predicted probabilities in the bottom decile ([&le;] 10th percentile) were classified as low risk, and those in the top decile ([&ge;] 90th percentile) as high risk. Results demonstrated heterogeneity in predicted risks across glycemic and cardiovascular outcomes. Predicted probability of developing CVD within the first year after T2D diagnosis ranged from a mean of 5.2% in the low-risk group to 28.9% in the high-risk group, while predicted probabilities of mean Hemoglobin A1c (HbA1c) [&ge;] 8% during the first year post-diagnosis ranged from 1.6% in low-risk to 55.1% in high-risk group. Patients with HbA1c at diagnosis [&ge;] 8% had higher predicted probabilities of first-year post-diagnosis mean HbA1c [&ge;] 8% (53.3% vs. 1.9%) and high HbA1c coefficient of variation (18.7% vs. 3.1%) compared with those with HbA1c [&le;] 6.5%. Incorporating early clinical outcomes refined later risk predictions, with long-term CVD risk reaching 33.5% among high-risk individuals. The proposed model achieved predictive performance comparable to conventional machine learning approaches while providing interpretable relationships for risk stratification in primary care populations.