When drug discovery fails: scientists share their frustrations with the process
In clinical trials, there are many times (and ways) a therapeutic can come up short. In clinical trials, there are many times (and ways) a therapeutic can come up short.
Academic Intelligence · Curated Daily
AcademicHub aggregates real-time literature from top journals and preprint platforms. Build your personal research radar and let large language models compile cross-disciplinary analysis briefings automatically.
In clinical trials, there are many times (and ways) a therapeutic can come up short. In clinical trials, there are many times (and ways) a therapeutic can come up short.
arXiv:2606.16056v1 Announce Type: new Abstract: Dysglycemia, encompassing both prediabetes and diabetes, affects huge numbers of adults worldwide, yet many of them remain undiagnosed. We developed and validated machine-learning (ML) models for non-invasive screening of dysglycemia risk that require no laboratory tests. Pooling data from the National Health and Nutrition Examination Survey (NHANES) 2017–2023 (n=14,352), we trained six ML models with stratified 5-fold cross-validation and compared them with two established clinical risk scores. LightGBM achieved the highest area under the receiver operating characteristic curve (AUC=0.820, 95% CI: 0.806–0.835), outperforming the Finnish Diabetes Risk Score (0.745) and American Diabetes Association Risk Test (0.783). SHAP analysis identified age, race/ethnicity, and waist-to-height ratio as the most influential predictors. Subgroup analyses confirmed consistent performance across demographic strata (AUC: 0.735–0.832). These results demonstrate the feasibility of explainable, laboratory-free dysglycemia screening for deployment in community settings and self-tracking health applications.
arXiv:2507.21164v2 Announce Type: replace-cross Abstract: Unsupervised anomaly detection (UAD) aims to detect anomalies without labeled data, a necessity in many machine learning applications where anomalous samples are rare or not available. Most state-of-the-art methods fall into two categories: reconstruction-based approaches, which often reconstruct anomalies too well, and decoupled representation learning with density estimators, which can suffer from suboptimal feature spaces. While some recent methods attempt to couple feature learning and anomaly detection, they often rely on surrogate objectives, restrict kernel choices, or introduce approximations that limit their expressiveness and robustness. To address this challenge, we propose a novel method that couples representation learning with an analytically solvable One-Class SVM (OCSVM), through a custom loss formulation that directly aligns latent features with the OCSVM decision boundary. The model is evaluated on two tasks: a \deleted{new} benchmark based on MNIST-C, and a challenging brain MRI \deleted{subtle} lesion detection task. Unlike most methods that focus on large, hyperintense lesions at the image level, our approach succeeds to target small, non-hyperintense lesions, while we evaluate voxel-wise metrics, addressing a more clinically relevant scenario. Both experiments evaluate a form of robustness to domain shifts, including corruption types in MNIST-C and texture or population age variations in MRI. Results demonstrate performance and robustness of our proposed model, highlighting its potential for general UAD and real-world medical imaging applications. The source code is available at https://github.com/Nicolas-Pinon/uad_ocsvm_guided_repr_learning.
In transiting planetary systems, in which planetary sizes are accurately determined from transit observations, the presence of transit-timing variations1 (TTVs), especially when combined with radial velocity (RV) data, provides powerful constraints on masses and orbital eccentricities. Together, these measurements offer crucial insights into system architecture, formation mechanisms and dynamical evolution. We present long-term RV and transit/TTV monitoring of the relatively young star (age approximately 1 Gyr) TOI-201, revealing an exceptional multi-planet system composed of a hot super-Earth (SE) size planet transiting every 5.8 days, a warm Jupiter (WJ) on a 53-day orbit and an eccentric (e = 0.62) low-mass brown dwarf (BD) on an approximately 8-year orbit, with an estimated mass MBD of about 16 Jupiter masses. The BD is the longest-period transiting substellar object ever characterized by means of RVs and the only one known to be coplanar with inner planets. The architecture of this system suggests that the SE was formed isolated and in the innermost region of the gaseous disk. On the other hand, the orbital configuration of the outer companions suggests a nearly in situ formation of both objects, with the WJ forming in a dense inner disk. Alternatively, the BD might have formed farther out and migrated inward, while increasing its eccentricity owing to interactions with the disk. Analysis of long-term radial velocity data and transit time variations, induced by a super-Earth, a warm Jupiter and a brown dwarf in a coplanar orbit around the relatively young star TOI201.
Abstract Purpose: Brain metastases (BM) far exceed primary CNS tumours and constitute the majority workload for neuro-oncology care providers. Currently, the cancer registries only capture synchronous BMs, which is only a small proportion of all BMs. We aim to develop and validate a natural language processing (NLP) algorithm that identifies brain metastases in radiology reports, enabling scalable surveillance of asynchronous BMs. Methods: Using population-based cancer registry data in Alberta, Canada, we identified a cancer cohort diagnosed between 2012–2019 with follow-up to 2022. All brain/head radiology reports at and post-cancer diagnosis were identified. Reports were sampled through a multi-phase approach and manually labeled for BM presence. We trained two Bio_ClinicalBERT models on the "Findings" and "Impressions" sections, respectively, and took the maximum predicted probability as the report-level prediction. Internal and external validation used reports from the Canadian provinces of Alberta, Ontario, and British Columbia. Results: The models were trained on 1,879 samples. For internal validation, 1,833 reports from 357 patients were tested. At a probability threshold of 0.4, the model achieved a sensitivity of 0.888 and precision of 0.499. The ensemble substantially outperformed single-section models, which achieved sensitivities of only 67.8% (Findings) and 74.2% (Impressions). On external validation, sensitivity was 0.918 in Ontario and 0.726 in British Columbia, demonstrating robustness across diverse data distributions. Conclusions: An NLP-based pipeline processing both Findings and Impressions sections has been developed and validated in three Canadian provinces. It meets cancer registry operational requirements and to be implemented into the surveillance workflow in Alberta and British Columbia, providing a foundation for population-level BM surveillance.
arXiv:2406.18855v2 Announce Type: replace Abstract: Let $S_n$ denote the set of permutations of $n$ labels. We consider a class of Gibbs probability models on $S_n$ that is a subfamily of the so-called Mallows model of random permutations. The Gibbs energy is given by a class of right invariant divergences on $S_n$ that includes common choices such as the Spearman foot rule and the Spearman rank correlation. Mukherjee in 2016 computed the limit of the (scaled) log partition function (i.e. normalizing factor) of such models as $n\rightarrow \infty$. Our objective is to compute the exact limit, as $n\rightarrow \infty$, without the log. We conjecture that this limit is given by the Fredholm determinant of an integral operator related to the so-called Schrödinger bridge probability distributions from optimal transport theory. We provide partial evidence for this conjecture, although the argument lacks a final error bound that is needed for it to become a complete proof.
arXiv:2606.07140v2 Announce Type: replace Abstract: We experimentally demonstrate an improved optical biasing scheme for superconducting nanowire single-photon detectors (SNSPDs), which employs a cryogenic InGaAs-InP photodiode (PD) as a local bias source. It is found that, under illumination from a stable external light source, this PD generates a stable photocurrent in a cryogenic environment (~2.3 K), with fluctuations in the photocurrent primarily attributed to fluctuations in the incident optical power. Furthermore, by screening and effectively blocking stray photons leaking from the PD, which give rise to background dark counts, we have achieved an SNSPD exhibiting an ultra-low intrinsic dark count rate of 1e-4 cps. Utilizing this improved optical biasing technique, our SNSPD achieved performance comparable to that obtained under conventional electrical biasing: a system detection efficiency of 80.7%, a background dark count rate of 32.6 cps, and a minimum timing jitter of 57.5 ps. These results indicate that cryogenic-PD-based optical biasing serves as a viable, low-noise, and low-jitter alternative to traditional electrical biasing. Moreover, this work offers useful design guidance for the future development of PD-based low-noise bias sources and for the construction of all-photonic SNSPD systems tailored for high-precision quantum photonics applications.
Multimodal Large Language Models have achieved remarkable progress in short-form audio-video understanding, yet long-form audio-video comprehension remains challenged by limited context windows and severe information redundancy. To address these bottlenecks, we propose AVOC, a framework for long-form audio-video understanding in Omni-modal Large Language Models. AVOC introduces a learnable token compression module between the modality encoders and the LLM backbone. We reframe multimodal token compression as a top-$K$ retrieval problem: given a fixed context budget, the module must retrieve a compact subset of tokens that best supports answering the user query. We draw inspiration from three classical Information Retrieval criteria for selecting informative units from a large candidate pool: relevance, importance, and diversity. AVOC instantiates each criterion as a tailored mechanism for audio-video understanding, and integrates them into a unified retrieval-style compression pipeline. Experiments show that AVOC achieves state-of-the-art performance on long-form audio-video benchmarks, surpassing the second-best model by 4.9 and 5.5 points in average accuracy on OmniVideoBench and LVOmniBench, respectively. Moreover, AVOC maintains robust performance on Audio-Video Needle-in-a-Haystack task at durations up to one hour.
arXiv:2606.17399v1 Announce Type: cross Abstract: When small transformers grok modular multiplication, prior work reports that the learned embedding has a "dense" Fourier spectrum requiring all frequencies. This contrasts with modular addition, where only a sparse set of key frequencies suffices. We show this density is an artifact of analyzing in the wrong basis. The natural Fourier transform for multiplication is not the standard additive DFT but the multiplicative character transform, which decomposes functions on the multiplicative group $(\mathbb{Z}/p\mathbb{Z})^*$ into its irreducible representations. Applying this transform to a grokked transformer trained on $a \cdot b \bmod 113$, we find the embedding spectrum becomes highly sparse (Gini coefficient 0.58 vs. 0.07 in the additive basis) with only 4 key frequencies carrying significant energy. Furthermore, 96.9% of MLP neurons are cleanly tuned to a single multiplicative frequency, and neuron activation heatmaps reveal 2D-periodic structure when reordered by the discrete logarithm. These results demonstrate the transformer reduces multiplication to addition in discrete-log space, implementing a "Discrete-Log Clock" algorithm analogous to Nanda et al.'s Clock algorithm for addition. The methodology generalizes: matching the analysis basis to the algebraic structure of the task reveals interpretable structure where standard tools see noise.
arXiv:2606.24038v1 Announce Type: cross Abstract: This note describes an integration of the sim-to-real performance estimate with betting (from Chen et al.) and the safe anytime-valid inference (from Ramdas et al.). Using the scaled simulators. The method produces efficient, reliable certificates for the mean estimate, an approach that is especially valuable in robot performance testing. This note gives a primary, self-contained account of the construction; preliminaries of the respective methods are kept at a minimum, and one shall refer to the original works for full detail. Some synthetic examples demonstrating the proposed algorithm can be found at https://github.com/ISUSAIL/Bet4Sim2Real-EProcess.
arXiv:2606.11918v1 Announce Type: new Abstract: Current Large Reasoning Models (LRMs) exhibit remarkable general capabilities but significantly underperform in spatial reasoning tasks. Existing approaches treat this gap as a knowledge deficit, relying on supervised fine-tuning (SFT) to ingest labeled spatial data from external vision sources or synthetic engines. In contrast, we argue that for many tasks, spatial reasoning capabilities are already present in pre-trained LRMs but require alignment through logical coherence under geometric 2D and 3D constraints. In this work, we propose a self-supervised reinforcement learning (RL) framework that targets the internal reasoning process without requiring ground-truth annotations. By formalizing the notion of consistency verifiers – reward functions that check for geometric and semantic consistency under transformations – we demonstrate that models can improve their spatial reasoning abilities. We use both image transformations, like flipping, and textual transformations, like swapping the order of objects in the question, and propose a new optimal transport-based RL strategy, OT-GRPO, which is a minimal-matching variant of group relative policy optimization tailored to pairwise verifiers. We show that this label-free consistency training approaches the accuracy of models trained with ground-truth supervision and achieves similar generalization across diverse tasks and data domains.
arXiv:2606.12662v1 Announce Type: cross Abstract: Speech enhancement models typically apply uniform capacity across all frequencies, disregarding the non-uniform spectral resolution of human hearing. We propose BASENet, a frequency-adapted architecture that partitions the spectrum into Bark-scale bands and assigns each a scaled-capacity encoder derived from critical-band density, automatically granting deeper branches to perceptually dense low frequencies and lighter ones to high frequencies. A cross-band attention module captures harmonic dependencies across bands through compact frequency-pooled representations at linear complexity. Built on inverted residual blocks with dense connectivity and a convolutional recurrent network, BASENet achieves 3.55 PESQ and STOI~96% on VoiceBank+DEMAND with only 0.83M parameters and 7.3 G~MACs, the fewest parameters among all methods with PESQ > 3.50. A causal variant (3.44 PESQ) surpasses several non-causal baselines, confirming suitability for real-time streaming on resource-constrained devices.
Warning: This paper contains several toxic and offensive statements. Modern large language models (LLMs) are typically aligned through large-scale post-training to ensure fair and reliable behavior. In this work, we investigate how easily such guardrails can be broken by Group Relative Policy Optimization (GRPO). We show that one-shot GRPO training on a single biased example is sufficient to induce systematic bias, with stereotype-driven reasoning generalizing across attributes, categories, and benchmarks. We further find that models differ in their susceptibility based on the initial likelihood of producing biased outputs. Our results reveal a critical vulnerability in post-training: alignment can be overridden by a single example.
Background. A recent meta-analysis by Dang et al. [1] concluded that enteral supplementation with docosahexaenoic acid (DHA), with or without arachidonic acid (ARA) did not significantly affect retinopathy of prematurity (ROP) outcomes in preterm infants. Of four eligible trials that supplemented both DHA and ARA, only two contributed to each ROP outcome analyzed, and severe ROP was not assessed. Methods. We replicated the eligibility criteria and search strategy of Dang et al., restricted to trials that supplemented both DHA and ARA, and reanalyzed three ROP endpoints (any ROP, ROP requiring treatment, and severe ROP [stage 3 and/or treated]) using complete outcome records from all eligible trials. Crude risk ratios (RR) were pooled by Mantel-Haenszel fixed-effect meta-analysis. Gestational age-adjusted odds ratios (adjOR) were pooled on the log scale by inverse-variance random-effects meta-analysis with restricted maximum likelihood (REML) estimation of between-study variance and Hartung-Knapp confidence intervals. Results. Five trials were included; one trial was identified in our replicated search but was excluded by Dang et al. without a stated rationale. The pooled estimate for any ROP was consistent with Dang et al. (RR 0.87 [95% CI 0.71-1.08]; adjOR 0.70 [0.46-1.08]). For ROP requiring treatment, the crude RR suggested a lower risk but did not reach statistical significance (RR 0.60 [0.35-1.04]), whereas the gestational age-adjusted estimate indicated lower odds (adjOR 0.47 [0.23-0.94]). For severe ROP, DHA+ARA supplementation produced a significant protective effect in both unadjusted and adjusted models (RR 0.56 [0.36-0.86]; adjOR 0.42 [0.19-0.96]). Conclusions. When all eligible trials contribute to each endpoint and severe ROP is included as an outcome, enteral DHA+ARA supplementation reduces severe ROP and is associated with lower odds of ROP requiring treatment after adjustment for gestational age. These findings differ from the conclusions of Dang et al. and support reconsideration of DHA+ARA supplementation as a strategy to reduce sight-threatening ROP in preterm infants.
Despite numerous attempts at mitigation since the inception of language models, hallucinations remain a persistent problem even in today's frontier LLMs. Why is this? We review existing definitions of hallucination and fold them into a single, unified definition wherein prior definitions are subsumed. We argue that hallucination can be unified by defining it as simply inaccurate (internal) world modeling, in a form where it is observable to the user. For example, stating a fact which contradicts a knowledge base OR producing a summary which contradicts the source. By varying the reference world model and conflict policy, our framework unifies prior definitions. We argue that this unified view is useful because it forces evaluations to clarify their assumed reference "world", distinguishes true hallucinations from planning or reward errors, and provides a common language for comparison across benchmarks and discussion of mitigation strategies. Building on this definition, we also connect our framework to HalluWorld, a complementary benchmark that instantiates fully specified reference world models for stress-testing model hallucinations.
arXiv:2606.15344v1 Announce Type: cross Abstract: Generative modelling requires efficient stochastic nonlinear transformations and physical platforms that can naturally realise them. We experimentally demonstrate that nonlinear optical systems operating in the strong light-matter coupling regime can serve as physical transformation layers for conditional generative modelling. Specifically, we develop a workflow in which room-temperature exciton-polariton condensates formed in organic dye microcavities act as a physical stochastic transform within a generative adversarial network and enable conditional digit-to-image translation. By using the nonlinear many-body dynamics and intrinsic stochasticity of polariton condensates, the workflow outperforms baseline approaches based on digitally injected perturbations. We find that polariton-enabled sampling via generative adversarial network (Polariton GAN) yields improved inception score, digit preservation accuracy and structural similarity compared with both digital sampling and laser-based systems. We further show that spatially correlated output variations can naturally regularise adversarial training and enhance output diversity. Our results establish polariton condensation as a new computational resource for generative modelling, opening a pathway towards physics-enhanced machine learning systems.
arXiv:2606.19676v1 Announce Type: cross Abstract: Diffusion models have achieved remarkable success in image and video generation and editing. While recent studies have extended these efforts toward motion editing, simultaneously transforming both motion and location-despite its practical importance-remains largely unexplored. To better understand robust motion-location editing, we first analyze the fundamental factors that degrade its quality. Based on this analysis, we propose TeleMorpher, one of the first one-shot frameworks to the best of our knowledge, for simultaneous motion-location editing. Our approach leverages motion priors, a target motion-centric video generated from an off-the-shelf model as motion-editing guidance, and the ground truth motion to enable more controllable and precise motion-location editing. Via this, our framework works as follows: (1) we first disentangle the protagonist and the background via pre-trained segmentation and inpainting models. (2) Then, we introduce a training-free pose warping that edits the protagonist's motion with the motion prior as the guidance. (3) The result of warped motion video is directly injected into a baseline motion editor during inference, mitigating the difference between source and target motions while preserving the appearance of the source video. (4) To enhance the reliability of quantitative evaluations, we propose two new LPIPS-based metrics that measure the background consistency before and after the motion editing and the fidelity of motion editing performance via measuring the difference between the extracted protagonist's skeletons from source and target videos. Experiments with in-the-wild videos and the TaiChi dataset demonstrate that TeleMorpher achieves superior performance across both quantitative and qualitative measurements (real-human evaluation), underscoring its effectiveness.
arXiv:2606.14108v1 Announce Type: cross Abstract: We introduce Adelic operation-preserved embeddings (AOE), a training-free representation that captures both a number's real value and its modular (p-adic) signatures. This construction preserves additive and multiplicative structure by design, turning numerical input into embeddings that "speak in the language of mathematics." Unlike prior approaches that rely on task-specific retraining, AOE is plug-and-play and drops seamlessly into existing architectures. On algebraic combinatorics benchmarks, it delivers consistent gains including the first-ever perfect accuracy on the Weaving Pattern task-while suggesting a principled path forward for overcoming the long-standing "number problem" in AI.
Accurate mechanical properties (or materials) Young's modulus ($E$), Poisson's ratio ($\nu$) and density ($\rho$) are essential for reliable physics simulation of digital worlds, but most 3D assets lack this information. We propose AdaVoMP, a method for predicting accurate dense spatially-varying ($E$, $\nu$, $\rho$) for input 3D objects across representations, improving the resolution, accuracy, and memory efficiency over the state-of-the-art. The foundation of our technique is a sparse and adaptive voxel structure SAV that efficiently represents both the input 3D shape and the material field output. We replace the fixed-voxel model of the most accurate prior method, VoMP, with a novel sparse transformer encoder-decoder model that learns to generate a unique SAV autoregressively for every input shape to represent its materials, achieving a resolution $16^3\times$ higher than prior art. Experiments show that AdaVoMP estimates more accurate volumetric properties, even with lesser test-time compute than all prior art. This allows us to convert high-resolution complex 3D objects into simulation-ready assets, resulting in realistic deformable simulations.
An experimental investigation of neural image classification on the CIFAR-10 benchmark is presented through fully connected and convolutional network formulations. The analysis emphasizes the complete learning pipeline: image vectorization, normalization, one-hot class encoding, supervised loss minimization, learning-rate selection, mini-batch training, convolutional feature extraction, max-pooling, and validation-based generalization assessment. A convolutional architecture with six convolutional layers and three max-pooling stages is evaluated for ten training epochs using a batch size of 128 and an Adam optimizer with a learning rate of 0.001. The validation accuracy reaches approximately 74.77%, while the validation loss begins to increase after the middle of training despite continued reduction in training loss. The resulting behavior illustrates the practical difference between representation learning and memorization, and it provides a compact experimental baseline for future studies on regularization, data augmentation, deeper architectures, and reproducible image-classification education.
arXiv:2606.15708v1 Announce Type: new Abstract: Welcome to the ninth edition of the AI Index report. As AI continues to advance rapidly, the question becomes whether the systems built around it can keep up. Governance frameworks, evaluation methods, education systems, and the data infrastructure needed to track AI's impact are struggling to match the pace of the technology itself. That gap between what AI can do and how prepared we are to manage it runs through every chapter of this year's report. New in this edition, the report tracks how AI is being tested more ambitiously across reasoning, safety, and real-world task execution, and why those measurements are increasingly difficult to rely on. It also features new estimates of generative AI's economic value alongside emerging evidence of its labor market effects, an analytical framework on AI sovereignty, and a science chapter developed in collaboration with Schmidt Sciences. For the first time, the report features standalone chapters on AI in science and AI in medicine, reflecting AI's growing impact across these two domains.
arXiv:2606.13607v1 Announce Type: new Abstract: When large language models (LLMs) fail to generalize or make haphazard errors in reasoning, it is often taken as evidence that LLMs are not truly reasoning, but rather performing a kind of pattern matching. The implication is that people's behavior does not exhibit the same types of failures because human reasoning uses principled and abstract world models. We evaluate human participants and 25 LLMs on their ability to engage in common-sense reasoning about a variety of everyday situations and observe similar patterns of errors in both people and models. We then identify the set of attention heads driving LLM responses and find that these heads implement a form of pattern-matching. These attention heads allow us to predict seemingly inexplicable reasoning errors in people caused by ostensibly irrelevant prompt details. Taken together, our results suggest that everyday causal reasoning in people and LLMs is more consistent with a form of pattern-matching than with abstract world models.
arXiv:2606.20526v1 Announce Type: new Abstract: Neurosymbolic systems such as DeepProbLog combine neural perception with probabilistic logic, but standard inference is associational. Counterfactual reasoning additionally requires a causal semantics for interventions and evidence. We introduce DeepSWIP, a single-world counterfactual semantics for DeepProbLog programs. Using neural materialization, we reduce fixed-context neural predicates to ordinary ProbLog choices, apply Single World Intervention Programs (SWIPs), and compute counterfactuals by weighted model counting (WMC) over a single transformed program. Under finite grounding and unique-supported-model assumptions, DeepSWIP is exact relative to the learned materialized FCM. The standard quotient-WMC form of ProbLog conditionals identifies active neural probabilities and explains intervention cleaning, calibration sensitivity, and rare-evidence instability. Experiments on MPI3D confirm the transformation against a DeepTwin construction against 12,000 queries, as predicted and a 2.14$\times$ inference speedup from avoiding the Twin's endogenous duplication. A SUMO HOV experiment shows that neural calibration degradation biases plug-in estimates, while a correctly scoped randomized-policy AIPW estimator removes most first-order bias for population mean and ATE estimands. Code is at https://github.com/saibib/deep_SWIP.
arXiv:2606.12690v1 Announce Type: cross Abstract: In this paper, we propose the Enhanced World Action Model (EWAM), a closed-loop online adaptation architecture built upon a pretrained and fully frozen Cosmos3 backbone network. Evaluated entirely under a zero-shot task protocol, EWAM is centrally focused on reducing the amount of additional deployment data required to adapt to new task layouts. Notably, no extra task-specific demonstration sets were introduced in any of the evaluations, and no fine-tuning was performed on the backbone network. Its performance gains stem entirely from an inference-time co-reasoning mechanism composed of four inserted lightweight neural layers: the Neural Experience Memory Layer located in the intermediate layers of the Diffusion Transformer (DiT) provides task-relevant execution context; the Neural Anomaly Detection Layer after the state prediction head monitors the divergence between predicted and actual states in real time; the Neural Policy Routing Layer dynamically selects direct execution, conservative replanning, or rollback recovery based on the anomaly severity; and the Neural Action Correction Layer refines the generated action chunks using execution diagnostics. Unlike naive feature fusion, the memory, anomaly detection, and correction modules are deeply integrated into the Cosmos3 forward path in a differentiable manner, with only the final routing decision being a discrete supervised one.
Background Bangladesh has experienced a rapid increase in cesarean section (CS) utilization over the past two decades. While previous studies have documented socioeconomic disparities in CS use, evidence on how wealth-related inequalities differ between public and private healthcare facilities remains limited. This study assessed the magnitude and drivers of socioeconomic inequality in CS utilization among facility-based births in Bangladesh. Methods We analyzed data from 3,008 facility-based births reported in the 2022 Bangladesh Demographic and Health Survey (BDHS). Survey-weighted multivariable logistic regression was used to identify factors associated with CS utilization. Wealth-related inequality was assessed using concentration curves and the Erreygers-corrected concentration index (ECCI). Regression-based decomposition of the standard concentration index was performed to quantify the contribution of socioeconomic, demographic, and healthcare-related factors to observed inequalities overall and separately for public and private facilities. Results Overall, 71.2% of facility-based births were delivered by CS, with substantially higher prevalence in private facilities (84.2%) than in public facilities (35.9%). Women delivering in private facilities had markedly higher odds of CS than those delivering in public facilities (adjusted odds ratio [AOR]: 9.07; 95% confidence interval [CI]: 7.17-11.47). Significant pro-rich inequality was observed overall (ECCI: 0.154; 95% CI: 0.117-0.191), with inequality substantially greater in public facilities (ECCI: 0.189; 95% CI: 0.114-0.264) than in private facilities (ECCI: 0.049; 95% CI: 0.014-0.084). Decomposition analysis showed that household wealth was the dominant contributor to inequality, particularly the richest wealth quintile, accounting for 81.5% of overall inequality, 63.8% in public facilities, and 109.7% in private facilities. Conclusions Wealth-related inequalities in CS utilization remain substantial in Bangladesh despite widespread use of the procedure. Although pro-rich inequality exists across both sectors, inequality is considerably greater in public facilities and is driven by different mechanisms across facility types. Policies should simultaneously improve equitable access to medically necessary CS and reduce unnecessary procedures, particularly within the private sector.