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01.
arXiv (CS.LG) 2026-06-11

SEDULity: A Proof-of-Learning Framework for Distributed and Secure Blockchains with Efficient Useful Work

arXiv:2512.13666v2 Announce Type: replace-cross Abstract: The security and decentralization of Proof-of-Work (PoW) have been well-tested in existing blockchain systems. However, its tremendous energy waste has raised concerns about sustainability. Proof-of-Useful-Work (PoUW) aims to redirect the meaningless computation to meaningful tasks such as solving machine learning (ML) problems, giving rise to the branch of Proof-of-Learning (PoL). While previous studies have proposed various PoLs, they all, to some degree, suffer from security, decentralization, or efficiency issues. In this paper, we propose a PoL framework that trains ML models efficiently while maintaining blockchain security in a fully distributed manner. We name the framework SEDULity, which stands for a Secure, Efficient, Distributed, and Useful Learning-based blockchain system. Specifically, we encode the template block into the training process and design a useful function that is difficult to solve but relatively easy to verify, as a substitute for the PoW puzzle. We show that our framework is distributed, secure, and efficiently trains ML models. We further demonstrate that the proposed PoL framework can be extended to other types of useful work and design an incentive mechanism to incentivize task verification. We show theoretically that a rational miner is incentivized to train fully honestly with well-designed system parameters. Finally, we present simulation results to demonstrate the performance of our framework and validate our analysis.

02.
medRxiv (Medicine) 2026-06-22

Panel-level multilocus methylation quantification in native cell-free DNA by PCR-compatible sequential enzymatic processing

DNA methylation is informative for liquid biopsy, but low template abundance, distributed methylation signals and workflow complexity limit implementation. Here we present Delta-HLD, a PCR-compatible methylation assay platform that quantifies methylation directly in native DNA through sequential hybridization, ligation and methylation-sensitive digestion. The assay co-reports methylation-dependent signals from multiple loci through a shared amplification architecture, generating a single panel-level PCR readout. We established the chemistry, optimized panel size and composition through model-guided experiments, and implemented the assay as a triplex qPCR workflow with per-sample internal process controls. Plasma proof-of-concept analyses showed discriminatory signal in CRC and proof-of-concept transferability to hepatocellular carcinoma. Additional platelet-retaining experiments identified a strategy to increase recovery of analyzable circulating templates while reducing genomic DNA recognition. Delta-HLD provides a compact PCR-compatible framework for low-input methylation analysis without base conversion.

03.
arXiv (quant-ph) 2026-06-24

Challenges in Barren Plateau Mitigation with Dynamic Parameterized Quantum Circuits

arXiv:2606.23751v1 Announce Type: new Abstract: Variational quantum algorithms (VQAs) are a promising paradigm for quantum advantage, yet their trainability is severely hampered by barren plateaus (BPs). Several works have proposed using dynamic parameterized quantum circuits (DPQCs) which intersperse unitary layers with parameterized CPTP maps (e.g. engineered dissipation, feedforward gadgets, or periodic resets), as a potential route around BPs. We unite this class of circuits into a formalization for DPQCs. We identify constraints on the nature and the structure of DPQCs if they are to prevent a significant number of parameters from becoming untrainable. We further show via purification and Pauli path analysis, a mechanism with which cost function anti-concentrates in DPQCs while still suffering from untrainability of a significant number of parameters. Our analysis reveals ways to design DPQCs that do not have an exponentially concentrated cost function, and our results suggest that BP mitigation via DPQCs is at least as hard as designing BP-free unitaries.

04.
arXiv (CS.CV) 2026-06-16

Hierarchical Fine-Grained Aerial Object Detection

Fine-grained aerial object detection, driven by the intrinsic granularity of real-world object categories, is crucial for advanced scene understanding in remote sensing. Existing methods largely inherit the paradigm of coarse-grained object detection, relying solely on single-label supervision and thus struggling to distinguish model-level categories with subtle structural differences. However, for each specific model (e.g., Boeing 787), structured prior knowledge such as attributes and hierarchies offers discriminative semantics across multiple granularities. Motivated by this, we present ExpertDet, a scheme that incorporates expert-informed cues to enhance fine-grained aerial object detection. Specifically, we design Vision-aware Masked Attribute Modeling (VMAM), which aligns attribute semantics with visual structures by reconstructing randomly masked attributes from visual cues, enabling the detector to capture subtle structural distinctions. We further propose Hierarchical Visual Instance Promotion (HierVIP), which builds a visual prototype tree based on hierarchical relations and imposes taxonomy-aware constraints to preserve cross-level semantic continuity while enhancing category discrimination. Moreover, we curate a new fine-grained object detection benchmark for Precise recognition of model-specific Ships and Planes from aerial imagery, PSP, covering 106 ship classes and 30 airplane models, respectively, featuring the most extensive collection of model-specific categories among existing aerial object detection datasets to date. We benchmark state-of-the-art object detection algorithms on the PSP benchmark. Extensive evaluation demonstrates that ExpertDet consistently outperforms other fine-grained competitors across hierarchy levels. The dataset, benchmark, and code are available at https://nnnnerd.github.io/PSP-Benchmark/.

05.
arXiv (CS.AI) 2026-06-18

What Does the Weight Norm Control in Grokking? Logit-Scale Mediation under Cross-Entropy

arXiv:2606.18465v1 Announce Type: cross Abstract: Grokking, the delayed jump from memorization to generalization, is usually tied to the weight norm: a smaller norm generalizes sooner. We ask what the norm actually controls. Holding the weight norm fixed by clamping and varying only an output temperature, we slide the grokking delay across its entire norm-induced range under cross-entropy; matching the effective logit scale back to baseline recovers about 85% of the delay at two moduli. Across a grid of norms and temperatures the delay collapses onto the logit scale alone (R2 = 0.97), with the norm adding 1-2% beyond it. The effect is loss-dependent: under mean-squared error the logit scale is pinned and the norm acts through a different route. A memorization control, a float64 softmax-collapse audit, and a no-LayerNorm transformer point to the same channel. Forking arms from one identical state, the delay follows the held norm value and not the clamp operation, which closes a rescaling-artifact concern. The proximal variable is the logit scale and the softmax saturation it drives; the weight norm is only an upstream handle. All numbers, tables, and figures reproduce from released code and data.

06.
arXiv (CS.AI) 2026-06-12

Generativism: Toward a Learning Theory for the Age of Generative Artificial Intelligence

arXiv:2606.12441v1 Announce Type: cross Abstract: The four dominant learning theories of behaviorism, cognitivism, constructivism, and connectivism show significant conceptual limitations as generative artificial intelligence (AI) proliferates in educational settings. These frameworks were formulated before the emergence of AI systems capable of generating, synthesizing, and reasoning about knowledge. This article critically examines each learning theory and identifies assumptions challenged by generative AI's affordances. Drawing on research in distributed cognition, extended mind, human-AI collaboration, AI literacy, cognitive offloading, and metacognition, the article proposes Generativism as a learning theory for the generative AI age. Generativism posits that learning increasingly occurs through the iterative co-construction of knowledge between human learners and AI systems. The proposed framework is organized around four principles: epistemic partnership, distributed agency, generative literacy, and adaptive metacognition. The framework offers a foundation for rethinking instructional design, learning, assessment, and expertise development in contexts where generative AI plays an integral role in cognition.

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

AI4SE and SE4AI Exploration: A Decade Looking Back and Forward

arXiv:2606.19630v1 Announce Type: new Abstract: The March 2020 INCOSE INSIGHT special issue on AI and Systems Engineering (SE) became the most downloaded issue in the publication's history and launched a research community that now draws over 250 registrants to its annual workshop. In this article, we trace the progress in AI and SE across three phases (labeled here foundational, applied, and LLM inflection) based on the authors' reading of the field's core papers, and describe our opinions of where the community has converged and where critical gaps remain. Separately, a human-AI agreement literature review leveraging both human expertise and six AI models was performed to assess the relevance of 1,712 INCOSE INSIGHT articles and 889 SERC publications. The results identify five critical research gaps and offer guidance for practitioners navigating AI adoption, assurance, and workforce transformation in SE. We share the agreement data and the AI4SE/SE4AI Explorer web application so readers can compare their own relevance judgments with the human and AI raters.

08.
arXiv (CS.AI) 2026-06-24

What Does ODRL Mean? A Cross-Level Ontological Grounding of Permissions, Prohibitions, and Duties in UFO-L

arXiv:2606.24344v1 Announce Type: cross Abstract: ODRL policy evaluators produce verdicts, but say nothing about the normative positions a policy brings into existence, the authority structures those positions presuppose, or who holds the power to declare a norm violated. We formulate the Cross-Level Design Principle: any normative language with violable, consequential norms requires both conduct-level positions (Permission, Duty, Right, No right) and competence-level positions (Power, Subjection, Immunity, Disability). Applying this to ODRL, we establish that prohibition is sanctioned (violation possible and consequential), that permission is underspecified across its behaviour parameter (open vs. closed world), and that the formal semantics covers achievement obligations only. We ground ODRL in UFO-L, mapping each activated rule to a simple legal relator and extending coverage from two to eight legal positions; violation-declaration authority, implicit in every existing evaluator, becomes an explicit Power-Subjection pair. All axioms are mechanically verified in Isabelle/HOL and across a 39-problem benchmark under Vampire, E, and Z3.

10.
arXiv (CS.AI) 2026-06-16

Discovering Symmetry Groups with Flow Matching

arXiv:2512.20043v3 Announce Type: replace Abstract: Symmetry is fundamental to understanding physical systems and can improve performance and sample efficiency in machine learning. Both pursuits require knowledge of the underlying symmetries in data, yet discovering these symmetries automatically is challenging. We propose LieFlow, a novel framework that reframes symmetry discovery as a distribution learning problem on Lie groups. Instead of searching for the symmetry generators, our approach operates directly in group space, modeling a symmetry distribution over a large hypothesis group $G$. The support of the learned distribution reveals the underlying symmetry group $H \subseteq G$. Unlike previous works, LieFlow can discover both continuous and discrete symmetries within a unified framework, without assuming a fixed Lie algebra basis or a specific distribution over the group elements. Experiments on synthetic 2D and 3D point clouds, ModelNet10 and a real-world MI-Motion dataset show that LieFlow accurately discovers continuous and discrete subgroups, significantly outperforming a state-of-the-art baseline, LieGAN, in identifying discrete symmetries.

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

RLCSD: Reinforcement Learning with Contrastive On-Policy Self-Distillation

On-policy self-distillation (OPSD) provides dense, token-level supervision for reasoning models by aligning a model's own distribution with the distribution it produces under privileged context, typically a verified solution. However, we show that the learning signal drawn from this distributional gap concentrates on style tokens rather than task-bearing ones, as the hinted model tends to produce more direct, shorter outputs. We term this pathology privilege-induced style drift, which destabilizes training or causes response length to shrink. To address this, we propose RLCSD (Reinforcement Learning with Contrastive on-policy Self-Distillation), which mitigates this drift by contrasting the teacher-student gap under a correct hint against that under a wrong hint, suppressing the style shift that conditioning on a hint tends to induce regardless of correctness, and yielding a signal that is more concentrated on task-bearing tokens. Experiments on Qwen3 (1.7B/4B/8B) and Olmo-3-7B-Think across mathematical and logical reasoning show that RLCSD consistently outperforms GRPO and prior OPSD methods. We further show that the contrastive principle is general: it plugs into existing OPSD methods to improve them, and its underlying insight extends to the broader cross-model on-policy distillation setting.

12.
arXiv (CS.CV) 2026-06-16

Multi-HMR 2: Multi-Person Camera-Centric Human Detection, Mesh Recovery and Tracking

Most advances in human mesh recovery (HMR) have focused on pelvis-centered recovery, overlooking metric 3D localization and detection accuracy in the camera coordinate system - two key factors for real-world applications such as human-robot interaction and social scene understanding. Current evaluation protocols often ignore these aspects, emphasizing per-person, root-centered recovery rather than camera-space perception. As a result, existing approaches rely on fixed camera assumptions or handcrafted post-processing, limiting their robustness and practical deployment. We introduce Multi-HMR 2, a simple yet robust DETR-based framework for Multi-person Camera-centric Human detection, mesh Recovery, and tracking. Multi-HMR 2 predicts a scene-consistent camera together with human meshes, enabling metric 3D localization without ground-truth intrinsics. Moreover, by distilling image-based memory features from SAM2, Multi-HMR 2 extends to tracking, achieving consistent identity association without video supervision. Despite its conceptual simplicity - no handcrafted components, no video input, and no ground-truth cameras - Multi-HMR 2 achieves state-of-the-art pelvis-centered performance while substantially improving detection accuracy and metric 3D localization.

13.
arXiv (quant-ph) 2026-06-17

Coherent Dark State Formation of a Lead-Vacancy Spin Qubit in Diamond

arXiv:2605.27841v2 Announce Type: replace Abstract: A lead-vacancy (PbV) center in diamond exhibits coherent emission above the liquid helium temperature, making it highly attractive for quantum network applications. Here, we report the magneto-optical and spin properties of PbV centers in diamond. We record a spin lifetime of 12 ms at 7.5 K under large off-axis magnetic field. Furthermore, we observe formation of the coherent dark state by coherent population trapping and estimate a spin dephasing time of 177 ns at 6.5 K. This work demonstrates the outstanding thermal robustness of the PbV spin compared to other group-IV centers above 4 K.

14.
arXiv (CS.LG) 2026-06-25

MINIF2F-DAFNY: LLM-Guided Mathematical Theorem Proving via Auto-Active Verification

arXiv:2512.10187v3 Announce Type: replace Abstract: LLMs excel at reasoning, but validating their steps remains challenging. Formal verification offers a solution through mechanically checkable proofs. Interactive theorem provers (ITPs) dominate mathematical reasoning but require detailed low-level proof steps, while auto-active verifiers offer automation but focus on software verification. Recent work has begun bridging this divide by evaluating LLMs for software verification in ITPs, but the complementary direction, LLMs for mathematical theorem proving in auto-active verifiers, remains unexplored. We present MINIF2F-DAFNY, the first translation of the widely-used mathematical benchmark miniF2F to an auto-active verifier: Dafny. We find that Dafny's automation alone solves 39-44% of problems with empty proofs, whereas many require substantial proof guidance in ITPs. We evaluate 8 off-the-shelf LLMs on proof generation, with the best model (Claude Opus 4.6) achieving 62.7% cumulative pass@4 on the full test set, improving over the 38.9% empty-proof baseline by 23.8 percentage points. These results show that auto-active verification offers a complementary empirical setting for AI-assisted mathematical reasoning, where LLMs provide high-level guidance while SMT automation handles low-level details. Our benchmark and evaluation infrastructure are publicly available on https://github.com/dafny-lang/miniF2F.

15.
arXiv (CS.CL) 2026-06-19

Analyzing Error Propagation in Korean Spoken QA with ASR-LLM Cascades

We analyze how automatic speech recognition (ASR) errors propagate through ASR-LLM cascades in Korean spoken question answering (SQA), focusing on downstream semantic failures that conventional ASR metrics cannot fully capture. Our analysis shows that the relative downstream degradation caused by ASR errors is consistent across LLMs with different absolute performance, suggesting that cascade degradation largely tracks ASR-stage information loss. We further identify single-character Korean ASR errors as a Korean-specific loss channel, where even a minimal transcription difference can change the intended question and degrade downstream QA performance. Finally, an auxiliary comparison shows that a large audio language model outperforms an ASR-LLM cascade with an approximately matched language backbone in noisy Korean SQA, indicating the potential of direct audio input to mitigate transcript-induced information loss.

16.
arXiv (CS.CV) 2026-06-19

Efficiently Linking Real Scenes with Synthetic Data Generation for AI-based Cognitive Robotics and Computer Vision Applications

AI vision models are a driving factor for the potential use case scenarios of cognitive robotics within in the industry and household applications. A large array of methods from semantic environment analysis towards 6D and grasping pose estimation have been proposed based on the latest AI achievements. However, such advancements require further strong and efficient methods w.r.t. training data and AI-architectures, which are capable in synergy to tackle current challenges, precision limits, and scalability beyond domain gaps. In this paper, we discuss these current limits and trends in the related state-of-the-art which are challenging those. Further we discuss our current work in progress on bridging the domain gap between simulations and real world applications by linking those in the training data generation.

17.
arXiv (CS.AI) 2026-06-15

Application of Artificial Intelligence and Machine Learning in Libraries: A Systematic Review

arXiv:2112.04573v2 Announce Type: replace-cross Abstract: As the concept and implementation of cutting-edge technologies like artificial intelligence and machine learning has become relevant, academics, researchers and information professionals involve research in this area. The objective of this systematic literature review is to provide a synthesis of empirical studies exploring application of artificial intelligence and machine learning in libraries. To achieve the objectives of the study, a systematic literature review was conducted based on the original guidelines proposed by Kitchenham et al. (2009). Data was collected from Web of Science, Scopus, LISA and LISTA databases. Following the rigorous/ established selection process, a total of thirty-two articles were finally selected, reviewed and analyzed to summarize on the application of AI and ML domain and techniques which are most often used in libraries. Findings show that the current state of the AI and ML research that is relevant with the LIS domain mainly focuses on theoretical works. However, some researchers also emphasized on implementation projects or case studies. This study will provide a panoramic view of AI and ML in libraries for researchers, practitioners and educators for furthering the more technology-oriented approaches, and anticipating future innovation pathways.

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

A Clinician-Centered Pipeline for Annotation and Evaluation in Ultrasound AI Studies

arXiv:2606.19174v1 Announce Type: cross Abstract: Clinician-centered evaluation is critical for validating medical AI systems, especially in ultrasound imaging where quantitative metrics do not always capture clinical usability. Existing medical image platforms primarily focus on dataset labeling. They lack integrated support for blinded model comparison and reproducible evaluation workflows. We present a clinician-centered pipeline for remote annotation and evaluation in ultrasound AI studies. The proposed pipeline uses a centralized server and lightweight browser interfaces to enable clinicians to perform annotation, blinded ranking, and review without local dataset downloads. The pipeline also supports multi-rater participation, centralized result aggregation, and automated statistical analysis. We validate the pipeline in a fetal ultrasound segmentation study with six raters spanning expert, generalist, and non-expert experience levels. The system automatically generated Spearman correlation, Kendall's $\tau$, and top-1 selection statistics. Results indicated moderate to strong agreement across experts and other groups. The blinded evaluation results showed a tendency for later active learning models to be preferred. These outcomes suggest that the pipeline can support clinician-centered annotation and reproducible human-\ac{AI} evaluation studies in ultrasound imaging. The proposed pipeline is available on \href{https://github.com/13204942/SonoRate}{GitHub}.

19.
Nature (Science) 2026-06-25

Base editing reveals an essential role for NANOG in human embryogenesis

Understanding how the first cell lineages in human development are specified and maintained has fundamental importance and clinical implications for regenerative medicine, infertility and pregnancy loss. While mouse models have provided valuable insights into transcription factors regulating early development, translating these findings to human embryos has been limited by ethical, technical and biological constraints. Functional studies of transcription factors in human embryos have been hindered by nuclease-based genome-editing approaches that induce genotoxicity1-3. To overcome this, we applied adenine base editing (ABE8e)4,5 to precisely target an exon splice donor site, resulting in a splicing defect and functional knockout of NANOG, representing the first application of base editing to study a developmental regulator in human embryos. This approach did not trigger genotoxicity and showed limited off-target editing. Loss of NANOG disrupts pluripotent epiblast specification and instead cells differentiate toward a primitive endoderm (yolk sac) or trophectoderm (placental) transcriptional programme. Retention of primitive endoderm differentiation in NANOG-edited human embryos reveals a functional compensation distinct from mouse, underscoring the importance of directly investigating human development. Our findings demonstrate an essential role for NANOG in human pluripotency and epiblast specification, and highlight the utility of base editing for functional interrogation of human development.

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

Equity with Efficiency: An Empirical Study of Tokenizers for Multilingual Large Language Models

Multilingual large language models (LLMs) depend on subword tokenization to bridge discrete text and continuous neural representation. State-of-the-art multilingual LLMs often use Byte-level Byte-Pair Encoding (BPE) tokenizers that structurally favor high-resource languages and Latin scripts. For speakers of underrepresented languages, particularly those across Southeast Asia, this bias inflates inference costs and widens cross-lingual capability gaps. We present the first systematic comparison of equitable tokenizers on a unified benchmark spanning 11 Southeast Asian languages. Beyond tokenizer-level analysis of compression efficiency and cross-lingual equity, we assess downstream task performance through controlled 1.5B-parameter language model training using the same training data. Our results show that Parity-aware BPE lies on the Pareto frontier of the efficiency-equity trade-off, achieving strong compression parity at competitive cost. Morphology-Driven Byte Encoding delivers the best semantic reasoning performance through morphologically richer representations, albeit at a higher computational expense. Byte Latent Transformer underperforms on downstream tasks, possibly because its architectural assumptions misalign with the constraints of limited low-resource training data. Together, our findings demonstrate that cross-lingual fairness and tokenization efficiency are not fundamentally at odds, and offer practical guidance for designing equitable multilingual models.

21.
arXiv (quant-ph) 2026-06-19

Topological Codes Based on Space Groups

arXiv:2606.20548v1 Announce Type: new Abstract: Topological codes form one of the most important classes of stabilizer codes. Most existing algebraic constructions and analyses of topological codes assume translation invariance. Here we show that topological codes can arise in more general settings by incorporating point group operations. The central construction is a class of Calderbank-Shor-Steane (CSS) codes called space-group codes, whose check operators are built from group-algebra templates over space groups that combine translations with point-group operations. We develop methods for analyzing topological properties of space-group codes using ring-modules and their invariant theory. At first glance, space-group codes might appear to complicate practical implementation; however, we find that they can exhibit greater locality than previous codes based purely on translations. Our framework thus extends the landscape of topological codes and opens up a broader design space for the co-design of topological codes with quantum computing platforms.

22.
arXiv (CS.AI) 2026-06-24

T2D-Bench: Evidence-Gated Evaluation of LLM Outputs for Type 2 Diabetes Using a Multi-Layer Clinical-Lifestyle Knowledge Graph

arXiv:2606.24145v1 Announce Type: new Abstract: Large language models (LLMs) can produce clinically fluent recommendations for type 2 diabetes while failing to satisfy guideline constraints or explicitly justify lifestyle-related glycemic claims. We present T2D-Bench, a reproducible benchmark and evidence-gated evaluation framework for testing whether LLM outputs satisfy explicit, graph-checkable evidence requirements. T2D-Bench is built on a multi-layer clinical-lifestyle knowledge graph that combines a biomedical spine (UMLS, DrugBank, SIDER), computable ADA Standards of Care rules, and lifestyle knowledge connected through a mechanistic bridge to glycemic laboratory effects. Across 100 structured vignettes spanning diagnosis, medication safety, and adversarial lifestyle conflicts, baseline outputs failed benchmark-defined evidence-path checks in 35% of cases for GPT-4o-mini and 33% for GPT-4o. The evidence gate detects unsupported omissions and uses constrained revision to bring outputs into verifier-level compliance with benchmark-defined evidence requirements. These results show that computable evidence constraints can make unsupported clinical omissions explicit, measurable, and correctable in diabetes-focused LLM outputs.

23.
arXiv (math.PR) 2026-06-18

A Unified Approach to Beta Moments, Combinatorial Identities, and Random Walks

arXiv:2605.05420v2 Announce Type: replace Abstract: The study of random walks has increasingly been popular across diverse disciplines such as statistics, mathematics, quantum physics, where they are used to model paths consisting of successive random steps in a mathematical space. A fundamental quantity of interest is the probability that a simple symmetric random walk returns to the origin after 2n steps. In this paper, we develop a unified probabilistic approach that connects the return probabilities in arbitrary dimensions with moment representations. Using this framework, we provide probabilistic proofs of several combinatorial identities involving beta and gamma functions, and derive new combinatorial identities in general dimensions.

24.
arXiv (CS.CL) 2026-06-25

Speech Codec Probing from Semantic and Phonetic Perspectives

Speech tokenizers are essential for connecting speech to large language models (LLMs) in multimodal systems. Speech tokenizers are expected to preserve both semantic and acoustic information for downstream understanding and generation tasks. However, emerging evidence suggests that the term "semantic" in speech processing does not align with linguistic lexical-semantic, leading to a mismatch between speech and text modality. In this paper, we systematically analyze the information encoded by several widely used speech tokenizers, evaluating their lexical-semantic and phonetic content through three tasks. Our results show that current tokenizers primarily capture phonetic rather than lexical-semantic structure, deriving practical implications for the design of next-generation speech tokenization methods. Code is released to public at https://github.com/Alexuan/codec_probing_release.

25.
medRxiv (Medicine) 2026-06-22

Cumulative Metabolic Exposure to Hyperglycemia and Risk of Cardiovascular and Limb Events in Peripheral Artery Disease

Background: Although diabetes is a potent risk factor for the development of peripheral artery disease (PAD), the effect of cumulative metabolic exposure to hyperglycemia on risk of cardiovascular or limb events in patients with PAD remains unclear. Methods: The Peripheral Artery Disease: Long-term Survival (PEARLS) is a longitudinal registry of Veterans with newly diagnosed PAD identified using a natural language processing approach. Included patients had ankle brachial index [≤]0.9 or toe brachial index [≤]0.7, and no history of lower extremity revascularization or major amputation. Among patients with diabetes in this cohort, we assessed cumulative exposure to hyperglycema based on a 24-month rolling average of hemoglobin (Hgb) A1c values, categorized as [≤]7%, >7% to [≤]8%, and >8%. Multivariable Cox regression models evaluated the association between categories of HgbA1c, modeled as a time-varying exposure, and risk of cardiovascular (CV: myocardial infarction or stroke) and limb (chronic limb threatening ischemia [CLTI] or major amputation) events. Results: Among 45,109 patients with new diagnosis of PAD and pre-existing diabetes, the mean HgbA1c at baseline was 7.5%, with nearly one-third (30.4%) having HgbA1c >8%. The mean age was 70.4 years, 19.8% were Black and 4% were Hispanic. Patients with baseline HgbA1c >8% were younger and compared to those with HgbA1c [≤]7%, more likely to have coronary disease, kidney disease, and obesity. Over a median follow up of 4.2 years, 8,306 (18.4%) patients experienced a CV event, and 8,199 (18.2%) experienced a limb event. The adjusted association between HgbA1c and hazard of CV events was 12% higher in patients exposed to HgbA1c >7% to [≤]8% (HR 1.12; 95%CI: 1.05-1.18) and 38% higher in those exposed to HgbA1c >8% (HR 1.38; 95%CI: 1.30-1.46), compared to HgbA1c 7% to [≤]8% (HR 1.20; 95%CI: 1.13-1.28) and HgbA1c >8% (HR 1.60; 95%CI: 1.51-1.70), respectively when compared to HgbA1c [≤]7%. These findings were consistent in subgroups based on age and severity of PAD. Conclusions: Among diabetic patients with PAD, cumulatiave metabolic exposure to hyperglycemia is associated with a markedly increased risk of clinical events, especially limb events.