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01.
arXiv (CS.LG) 2026-06-12

One Step Closer to Ground Truth: A Multi-Scale Residual-Aware Representation Learning Pipeline for Predicting Time Series Data

arXiv:2606.10678v2 Announce Type: replace Abstract: Transformer-based models have emerged as leading paradigms in time-series forecasting in recent years, employing self-attention mechanisms to capture long-range dependencies. Despite their success, these single-stage forecasting architectures exhibit persistent systematic residual biases arising from structural discrepancies, unmodeled stochastic components, or inadequate multi-scale temporal representations. This limitation persists when residuals are treated as irreducible noise, precluding adaptive correction of structured error patterns. To address this limitation, we introduce a two-stage, model-agnostic framework that explicitly decouples forecasting and residual learning into distinct stages of representation learning. A base transformer first generates the initial predictions. Subsequently, a dedicated meta-corrector dynamically models structured error patterns across multivariate channels, preserves cross-variable dependencies, and iteratively refines the residual bias of the base transformer. By formalizing this pipeline as a hypothesis space expansion, our framework addresses approximation limitations inherent in single-stage architectures, removes reliance on restrictive assumptions, and enables end-to-end learning of complex error dynamics. Evaluated on eight popular benchmark datasets using established protocols, our approach achieves state-of-the-art performance, with significant improvements in standard metrics (MSE, MAE). The results demonstrate the framework's ability to mitigate systematic biases and enhance robustness to complex temporal dynamics, advancing the practical applicability of transformer-based forecasting models.

02.
arXiv (CS.AI) 2026-06-11

SpikeDecoder: Realizing the GPT Architecture with Spiking Neural Networks

arXiv:2606.12287v1 Announce Type: cross Abstract: The Transformer architecture is widely regarded as the most powerful tool for natural language processing, but due to a high number of complex operations, it inherently faces the issue of high energy consumption. To address this issue, we consider Spiking Neural Networks (SNNs), which are an energy-efficient alternative to conventional Artificial Neural Networks (ANNs) due to their naturally event-driven approach to processing information. However, this inherently makes them difficult to train. Often, many SNN-based models circumvent this issue by converting pre-trained ANNs. More recently, attempts have been made to design directly trainable SNN-based adaptations of the Transformer model structure. Although the results showed great promise, the application field was computer vision. Moreover, the proposed model incorporates only encoder blocks. In this paper, we propose SpikeDecoder, a fully SNN-based implementation of the Transformer decoder block, for applications in natural language processing. In a series of experiments, we analyze the impact of exchanging different blocks of the ANN model with spike-based alternatives to identify trade-offs and significant sources of performance loss. We further investigate the role of residual connections and the selection of SNN-compatible normalization techniques. Besides the work on the model architecture, we formulate and compare different embedding methods to project text data into spikes. Finally, we demonstrate that our proposed SNN-based decoder block reduces the theoretical energy consumption by 87% to 93% compared to the ANN baseline.

03.
arXiv (CS.CL) 2026-06-18

Steerable Cultural Preference Optimization of Reward Models

It is essential for large language model (LLM) technology to serve many different cultural sub-communities in a manner that is acceptable to each community. However, research on LLM alignment has so far predominantly focused on predicting a unified response preference of annotators from certain regions. This paper aims to advance the development of alignment models with a more global outlook, that are able to accurately represent the preferences of subcommunities and do not exhibit excessive bias towards any of them. We focus on the development of reward models for this purpose and present a novel reward model training algorithm (SCPO) that can incorporate diverse cultural preferences in a balanced manner. Our method results in performance increases of the minority reward model of up to 7 points over the baseline model across two datasets, PRISM and GlobalOpinionQA, and across 7 countries. SCPO is up to 280% more training data-efficient than full-data finetuning of reward models. In addition, we perform analysis of bias by separately evaluating on the preference of subcommunities and show that excessive bias is mitigated via our weighting method. Our code is available at https://github.com/minsik-ai/Steerable-Cultural-Preference

04.
arXiv (CS.CL) 2026-06-11

Scenario-based Probing and Steering Cultural Values in Large Language Models–Extended Version

Large Language Models (LLMs) are deployed across cultural contexts but often reflect homogenized values inherited from training data. Evaluations of cultural alignment typically rely on direct prompting with survey-style questions, which frequently elicit neutral or safety-aligned responses and fail to capture underlying model preferences. We propose a framework for probing and steering latent cultural representations in LLMs along the two Inglehart–Welzel axes of the World Values Survey (WVS). By translating social value questions into scenario-based behavioral dilemmas, we extract token-level probabilities to measure implicit values and apply activation steering, optionally combined with country-conditioned prompting, to shift model behavior without retraining. Across three open-source LLMs and four target cultures, we find substantial variation in steerability and identify latent entanglement, where interventions along one cultural dimension induce shifts along another. This coupling mirrors correlations in human WVS data and persists across activation, prompt, and hybrid steering. It constrains axis-independent alignment, though general task performance is largely preserved.

05.
arXiv (CS.LG) 2026-06-17

Fast Nonparametric Conditional Independence Testing via Two-Stage Regression

arXiv:2606.18011v1 Announce Type: cross Abstract: Constraint-based causal discovery relies on repeated conditional independence tests, but fast nonparametric tests often sacrifice calibration, especially when variables depend on the conditioning set through nonlinear relationships. We introduce BLITZ (Broad-to-Local Independence Testing via residualiZation), a nonparametric conditional independence test designed to run well under a second while maintaining the accuracy needed for the thousands of queries performed by constraint-based causal discovery algorithms. BLITZ first removes broad smooth dependence on the conditioning set using low-order polynomial regression, then applies a small nonlinear feature map and residualizes those features with shallow tree regressions. The resulting statistic tests residual cross-covariance, with a moment-matched chi-square approximation to the null distribution. We show theoretically that the two-stage design reduces the effective complexity faced by the tree residualizers, allowing shallow trees to control residual conditional-mean bias while avoiding excessive overfitting. In simulations, BLITZ provides better null calibration than fast kernel, random-feature, and regression-based competitors while remaining among the fastest methods tested. In causal discovery experiments on synthetic graphs and flow-cytometry data, BLITZ yields more reliable endpoint orientations among retained adjacencies and competitive structural recovery. These results suggest that broad-to-local residualization is a practical route to calibrated, scalable nonparametric conditional independence testing for causal discovery.

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

Sectional Curvature for Kantorovich-Wasserstein and Hellinger-Kantorovich Geometries

arXiv:2606.14318v1 Announce Type: cross Abstract: We derive an explicit formula for the sectional curvature of the space ${\cal M}(M)$ of finite measures on a Riemannian manifold M. The space ${\cal M}(M)$ is equipped with the Hellinger-Kantorovich metric $HK$. Even in the case M=R^n, the curvature is comprised of two parts: the `lifted part' is negative, and the `twisted part' is positive. It will be analyzed in detail for the multidimensional torus. Our general approach to sectional curvature in geodesic spaces also leads to new insights into the curvature of the space $P_2(M)$ of probability measures on M equipped with the Kantorovich-Wasserstein metric $W_2$.

07.
arXiv (CS.CV) 2026-06-12

Distributional Loss for Robust Classification

This paper proposes a novel loss concept for supervised classification tasks. Rather than enforcing a direct mapping from each input sample to a single assigned label, we define an optimization objective over all classifier outputs as a bimodal Gaussian distribution. This softer target formulation implicitly captures class ambiguity, mitigates overfitting, and encourages the learning of more robust decision boundaries, all without requiring additional label information. Experimental results demonstrate consistent improvements in robustness, with particularly pronounced gains in low-data regimes, while requiring only minimal modifications to standard training pipelines.

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

Shopping Reasoning Bench: An Expert-Authored Benchmark for Multi-Turn Conversational Shopping Assistants

Conversational shopping assistants now serve hundreds of millions of customers, yet no existing benchmark jointly evaluates the open-ended multi-turn reasoning, domain expertise, and criterion-level quality that real shopping conversations demand. Shopping reasoning is unique among language model applications. Unlike factual question answering or verifiable code generation, it requires balancing subjective preferences, budget constraints, and cross-product trade-offs across multi-turn dialogue, capabilities absent from previous e-commerce and general-purpose benchmarks. We introduce the Shopping Reasoning Bench, an expert-authored benchmark of 525 missions (232 single-turn, 293 multi-turn) with 10863 importance-weighted binary rubrics authored by retail domain experts. These criteria are organized under a taxonomy of five reasoning categories and fifteen subcategories covering diverse demands such as preference refinement, trade-off analysis, and compatibility assessment. An evaluation of nine models across three families (GPT, Claude, Gemini) shows that pass rates reach only 57–77% overall. On multi-turn missions, all models score 13–29 points lower on optional above-and-beyond criteria than on required ones, and performance degrades 4–18 points as conversations progress. These gaps show that current models handle basic shopping assistance but fall short of expert-level advice, making Shopping Reasoning Bench a challenging testbed for future shopping assistant development.

09.
arXiv (quant-ph) 2026-06-19

Application and quantum properties of superpositions of oppositely squeezed states

arXiv:2511.03204v2 Announce Type: replace Abstract: We show that superpositions of oppositely squeezed states – non-Gaussian Schr{\"{o}}dinger-cat-like states – exhibit enhanced nonclassical features and provide an entanglement advantage in the small-squeezing regime. These states possess photon-number structures distinct from conventional coherent-state cat states, and we analyze their Wigner functions and the entanglement generated when they are injected into a 50-50 beam splitter. As a practical application, we demonstrate that they enable a high-quality heralded single-photon source whose second-order intensity correlation function is smaller than that obtained from a pure two-mode squeezed vacuum state. We further propose a linear-optical heralding scheme that approximates these superpositions without requiring strong Kerr nonlinearities. Our results indicate that the superposition of oppositely squeezed states is a promising non-Gaussian resource for quantum information processing, particularly for single-photon generation.

11.
arXiv (CS.AI) 2026-06-17

Lean4Agent: Formal Modeling and Verification for Agent Workflow and Trajectory

arXiv:2606.06523v2 Announce Type: replace Abstract: Equipping Large Language Models (LLMs) to execute reliable multi-step workflows has become a central challenge in artificial intelligence. Despite recent advances in LLMs' agentic capabilities, most agent systems still lack formal methods for specifying, verifying, and debugging their workflow and execution trajectories. This challenge mirrors a long-standing problem in mathematics, where the ambiguity of natural languages (NLs) motivates the development of formal languages (FLs). Inspired by this paradigm, we propose **Lean4Agent**, to the best of our knowledge, the first framework that uses Lean4, a dependent-type FL to model and verify agent behavior. **Lean4Agent** launches **FormalAgentLib**, an extensible Lean4 library for formally modeling and verifying agent workflows' semantic consistency under explicit assumptions, and enabling localization of execution-time failures revealed by trajectories. Building on **FormalAgentLib**, we further develop **LeanEvolve**, which applies results in **FormalAgentLib** to revise workflows to enhance its capability. Extensive experiments on a hard problem subset of SWE-Bench-Verified and a subset of ELAIP-Bench across 5 leading LLMs indicate that the verification-passing workflows outperform the failing ones by an average of **11.94%**, and **LeanEvolve** further improves SWE performance by **7.47%** on average. Furthermore, **Lean4Agent** establishes a foundation for a new field of using expressive dependent-type FL to formally model and verify agent behavior.

12.
arXiv (CS.CV) 2026-06-11

AnchorEdit: Maintaining Temporal Consistency in Multi-turn Image Editing via Causal Memory

Multi-turn image editing is essential for iterative design, yet current models often struggle with identity drift and error accumulation over successive steps. While existing research leverages video priors for consistency, their reliance on bidirectional attention is fundamentally misaligned with the causal, sequential nature of interactive editing. In this paper, we propose AnchorEdit, the first autoregressive (AR) diffusion-based framework designed specifically for high-resolution, long-term multi-turn editing. AnchorEdit bridges the gap between video priors and causal inference through a three-stage training curriculum: identity-preserving sing-turn pretraining, causal AR forcing fine-tuning with a novel self-rollout strategy to mitigate exposure bias, and consistency distillation for efficient 4-step generation. During inference, we introduce a memory mechanism to anchor the initial subject identity and ensure stable extrapolation across extended editing trajectories. To evaluate performance, we provide a new high-resolution multi-turn editing benchmark designed to stress-test long-horizon stability. Extensive experiments demonstrate that AnchorEdit achieves state-of-the-art results, maintaining exceptional subject fidelity and instruction following even over 10+ interaction rounds.

13.
arXiv (CS.LG) 2026-06-11

Loss Landscape Diagnosis for Gradient-Based Gray-Scott System Inversion: Disentangling the Roles of PINN Components

作者:

arXiv:2606.11258v1 Announce Type: new Abstract: Gradient-based inversion of reaction-diffusion systems is typically approached via surrogate models or physics-informed neural networks (PINNs), while the most direct route, backpropagation through the PDE's structure itself, has largely been avoided. We pursue this direct route as a diagnostic probe, backpropagating a steady-state loss through unrolled Gray-Scott simulation to recover its parameters, with no surrogate or neural-network augmentation. Optimization fails to converge, and plotting the landscape directly locates the failure in its geometry – flat plateaus with no gradient signal, bounded by sharp cliffs that align with bifurcation boundaries – a structure that recurs across loss functions and is inherited however the gradients are routed to parameters. Reading this minimal setup as an ablation of PINN, we disentangle each component's role: with the neural network fixed, the residual loss is quadratic in the PDE parameters and yields a smooth landscape, so it alone already avoids the pathology, by implicitly encoding the full PDE dynamics across all initial conditions. The neural network, for its part, cannot repair an ill-posed parameter subspace, and so serves only to complete the observed data – a division of labor not previously made explicit. These findings carry concrete design implications for PINN-type methods and a broader heuristic on when added dimensions actually help.

14.
arXiv (CS.CV) 2026-06-18

EDoF-NeRF: extended depth-of-field neural radiance fields using a coded aperture camera

We propose a method for extending the depth-of-field (DoF) to construct high-fidelity neural radiance fields (NeRF) – an emerging technique for rendering photorealistic novel views from a dataset of images captured at different viewpoints, based on implicit neural representations. The trade-off between DoF and light quantity is inherent not only in conventional cameras but also in NeRF, since the datasets used by NeRF are captured by these cameras. To address this issue, we introduce a coded aperture placed at the camera pupil, preserving spatial frequency components under defocused conditions. We develop a camera model incorporating coded apertures into NeRF, allowing direct input of coded images and enabling the generation of novel views with an extended DoF. We validate the proposed method, termed extended DoF-NeRF (EDoF-NeRF), through simulations and experiments, demonstrating its superior performance compared to conventional aperture cameras.

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

Physics-Informed Neural Network with Squeeze-Excitation-like Attention

arXiv:2606.19853v1 Announce Type: new Abstract: We introduce SEA-PINN, a novel architecture that incorporates a Squeeze-Excitation-like attention mechanism into physics-informed neural networks to dynamically recalibrate the importance of neurons across layers. A key feature of SEA-PINN is its highly stable initialization. On 17 out of 20 benchmark problems, SEA-PINN exhibit nearly negligible variance and significantly reduced initial loss, establishing a quasi-deterministic and favorable starting point for optimization. Notably, without employing Fourier feature embeddings or periodic activation functions, SEA-PINN attained competitive accuracy (83\% vs. 90\% improvement relative to FNN-PINN on the high-frequency case 7) as compared with TSA-PINN-a model specifically engineered for high-frequency problems via learnable frequencies in sinusoidal activations. Furthermore, integrating SEA-PINN into TSA-PINN boosted performance by 42.49\%. These results underscore SEA-PINN as a lightweight plug-in module that enhances nonlinear representation power, promotes more robust and efficient convergence, and strengthens the overall reliability of physics-informed learning.

16.
arXiv (quant-ph) 2026-06-15

Nanostructure modelling with early fault tolerant quantum computers

arXiv:2606.06442v2 Announce Type: replace Abstract: Semiconductor nanostructures are central to many developing technologies. Notably, double quantum dots are especially important for semiconductor spin-qubit architectures, quantum sensing applications, and quantum-dot solar cells. Accurate modelling is highly desirable but conventional methods can struggle when dynamics involve more than two interacting electrons. In this work, we present a quantum simulation framework capable of addressing multi-electron double quantum dots. We adopt an efficiently scaling 1$^st$ quantised representation of the system and develop algorithms based on both Trotterisation and Qubitisation. Incorporating insights from classical simulations enables us to produce resource estimates that are more realistic than those obtained from theoretical error bounds. Using a standard surface code model with physical noise at $10^{-3}$, our results indicate that the ground-state energy of four electrons in a double quantum dot can be estimated in approximately 22 hours using 226k physical qubits, or an eight-electron system in 3.3 days with 314k qubits (with runtimes falling dramatically when more qubits are available). We anticipate that incorporating recent advances in surface code architectures may reduce these costs significantly further. Our results suggest that early fault-tolerant quantum computers may become valuable tools for designing mature-era quantum technologies.

17.
arXiv (CS.AI) 2026-06-19

Systematic Study of Dysarthric Speech Recognition: Spectral Features and Acoustic Models

arXiv:2606.19793v1 Announce Type: cross Abstract: The challenge associated with recognizing dysarthric speech primarily arises from pronounced acoustic variability attributed to impaired articulatory precision. Past research has demonstrated improved recognition through the use of hybrid DNN/HMM sequence discriminative training. This paper presents a comprehensive investigation of various combinations of acoustic features tailored to different Acoustic Models, offering suitable feature selections for each. The incorporation of Pitch features notably improved recognition performance, especially for sentence recognition tasks involving dysarthric speech. Through a systematic examination of the TORGO database, we have demonstrated the potential to enhance the performance of the state-of-the-art Factorized Time Delay Neural Network (F-TDNN) model for recognizing dysarthric speech. Our methods, implemented with the F-TDNN model, resulted in a 4.65\% relative improvement in isolated word recognition and a 4.63\% relative improvement in sentence recognition for dysarthric speech, compared to previous research. This improvement effectively compensates for speech variability, attributable to our deliberate selection of the number of overlapping frames between consecutive training example chunks.

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

Characterizing Brazilian Atlantic Forest Restoration Outcomes with Geospatial AlphaEarth Embeddings

作者:

The Atlantic Forest in Brazil is a critical biodiversity hotspot, yet less than 12-15% of its original cover remains. Although monitoring forest restoration on a large scale is essential, traditional methods are limited by the impracticality of on-the-ground reporting on such a scale and by the saturation of remote-sensing indices such as NDVI. Furthermore, reforestation is a gradual process as opposed to the rapid spectral changes caused by deforestation. In this study, we examine 1,729 restoration sites in S\~ao Paulo, using satellite embeddings from the AlphaEarth Foundation's model to evaluate their effectiveness in characterising early restoration success. We introduce the concept of a 'Reference Trajectory Embedding', defining a metric of restoration success based on cosine similarity to reference sites of mature secondary forest. We observe distinct clusters in embedding space according to different land use and land cover (LULC) types, and we can identify sites with clear change vectors. However, the signal can be noisy, and embeddings may require further fine-tuning to capture and predict site metadata beyond LULC.

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

A Human-in-the-Loop Label Error Detection Framework Applied to Arabic-Script HTR Datasets

Despite recent advances, Handwritten Text Recognition (HTR) for Arabic-script languages still lags behind Latin-script HTR. Part of the problem is dataset quality. To help closing this gap, we propose a two-stage framework (CER-HV) for detecting label errors. Stage 1 (CER) is a Character-Error-Rate-based noise detector built on a Convolutional Recurrent Neural Network (CRNN) architecture. Stage 2 (HV) is the Human-In-The-Loop (HITL) Verification of noisy samples detected by the first stage. Applying the CER-HV framework on multiple Arabic-script datasets can identify samples with label errors including transcription, segmentation, orientation, and non-text content errors that can markedly affect HTR performance. These errors were identified by the first stage of the framework with up to 90percent (top-50) precision. We also show that our CRNN achieves state-of-the-art performance across five of the six evaluated datasets, reaching 8.46 percent Character Error Rate (CER) on KHATT (Arabic), 8.22 percent on PHTI (Pashto), 10.59 percent on Ajami, and 10.11% on Muharaf (Arabic), all without any data cleaning. We establish a new baseline of 11.3 percent CER on the PHTD (Persian) dataset. Applying CER-HV improves evaluation CER by up to 1.8 percentage points after dataset cleaning and retraining. Although our experiments focus on documents written in an Arabic-script language, the framework is general and can be applied to other text recognition datasets

21.
arXiv (CS.CL) 2026-06-15

Did You Forget What I Asked? Prospective Memory Failures in Large Language Models

作者:

Large language models often fail to satisfy formatting instructions when they must simultaneously perform demanding tasks. We study this behaviour through a prospective memory inspired lens from cognitive psychology, using a controlled paradigm that combines verifiable formatting constraints with benchmark tasks of increasing complexity. Across three model families and over 8,000 prompts, compliance drops by 2-21% under concurrent task load. Vulnerability is highly type-dependent: terminal constraints (requiring action at the response boundary) degrade most, with drops up to 50%, while avoidance constraints remain comparatively robust. A salience-enhanced format (explicit instruction framing plus a trailing reminder) recovers much of the lost compliance, restoring performance to 90-100% in many settings. Interference is bidirectional: formatting constraints can also reduce task accuracy, with one model's GSM8K accuracy dropping from 93% to 27%. In additional stacking experiments, joint compliance declines sharply as constraints accumulate. All results use deterministic programmatic checkers without an LLM-as-judge component on publicly available datasets.

22.
arXiv (CS.AI) 2026-06-16

Input-Dependent Fisher Information for Local Sensitivity Analysis of Medical Image Classifiers

arXiv:2606.16362v1 Announce Type: cross Abstract: Deep neural networks have achieved strong performance in medical image classification, but often work like black-box. Commonly used post-hoc interpretation methods often provide heuristic visualizations whose relationship to the classifier's predictive distribution is indirect. This work introduces a local sensitivity analysis framework based on the input-dependent Fisher Information Matrix (iFIM) of a trained classifier. The iFIM characterizes how the classifier's predictive distribution changes under infinitesimal perturbations of the input image. By using a Gram-matrix formulation, the nonzero eigenspectrum of the iFIM can be recovered without explicitly forming the full image-dimensional Fisher matrix. The leading iFIM eigenspace is then used to project an input image into a high local-sensitivity component and its orthogonal component. These components provide a model-intrinsic description of local predictive sensitivity, rather than a conventional pixel-wise attribution heatmap or a causal segmentation of task-relevant anatomy. The framework is evaluated on controlled and clinical medical image classification tasks using multiple classifier architectures. Perturbation-based experiments show that high-sensitivity iFIM components are more strongly coupled to changes in predictive confidence and classification performance than lower-sensitivity complementary components. The results support the iFIM framework as a principled tool for analyzing local decision sensitivity and for complementing existing attribution-based interpretability methods in medical imaging.

23.
arXiv (CS.CV) 2026-06-19

Addressing Detail Bottlenecks in Latent Diffusion for RGB-to-SWIR Image Translation

Latent diffusion models (LDMs) enable efficient image-to-image translation but discard fine spatial details during compression, degrading downstream perception tasks. We identify two bottlenecks: the autoencoder, which loses spatial information, and the conditioning pathway, which further degrades the source signal through naive downsampling. We propose two lightweight, backbone-agnostic fixes: a Source-Conditioned Autoencoder (SCAE) that injects high-resolution source features into the decoder via skip connections, and a Learnable Guidance Encoder (LGE) that replaces naive downsampling with a learned conditioning signal. Evaluated on RGB-to-SWIR translation for driving scenes with two denoiser backbones (U-Net and DiT), our approach improves detection mAP by up to 2x over the latent diffusion baseline, with up to 3.4x gains on small objects (COCO-small,

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

Not What, But How: A Framework for Auditing LLM Responses across Positioning, Generalization, Anthropomorphism, and Maxims

Large language models (LLMs) are being increasingly used to answer subjective, information-seeking questions, where users are sensitive to how responses are communicated, not just whether the answers are correct. Existing LLM evaluations for subjective cultural queries largely focus on factual correctness, ignoring how the response is framed. To this end, we introduce FRANZ, an automated FRAmework for respoNse characteriZation to conduct communicative audit of LLM responses along four dimensions: cultural positioning, use of generalizing language, anthropomorphic cues, and adherence to conversational maxims. To enable this evaluation, we contribute SQUARE - a corpus of 376k subjective questions sourced from 57 subreddits, and mapped to 7 countries and 19 question categories. We demonstrate FRANZ's applicability by scoring responses from three open-weight LLMs. We observe that LLMs show statistically significant differences in the frequency with which they employ each response characteristic. Unlike single-dimensional audits, FRANZ reveals that insider positioning and anthropomorphism are positively coupled, with the degree of coupling varying by country, providing a diagnostic lens for identifying framing divergences.

25.
medRxiv (Medicine) 2026-06-22

Referral pathways, ETAT triage acuity, and inpatient outcomes among children presenting to a national tertiary paediatric emergency unit in Ghana: a prospective cohort study

Emergency referral systems in sub-Saharan Africa are fragmented, and children reaching tertiary facilities through different referral pathways often arrive in advanced clinical states. Prospective data simultaneously characterising referral patterns, triage acuity at presentation, diagnostic case mix, and inpatient mortality at a national tertiary paediatric emergency unit are lacking from West Africa. This prospective cohort study enrolled 675 consecutively presenting children aged one month to 12 years at the Paediatric Emergency Unit of Korle Bu Teaching Hospital, Accra, Ghana, from February to December 2019. The primary outcome was all-cause inpatient mortality. Key variables collected included referral status and facility tier, Emergency Triage Assessment and Treatment (ETAT) triage category, ICD-10 diagnostic classification, Oyedeji socioeconomic classification, and time from symptom onset to PEU registration. Crude odds ratios were computed for all candidate predictors. Multivariable logistic regression was conducted using complete case analysis (n = 613). Of 675 children, 63.0% (n = 425) were referred from another health facility; referred children had higher ETAT emergency triage category rates than self-presenting children (32.7% vs 27.6%, p < 0.001). Overall inpatient mortality was 9.9% (67/675). Mortality varied by referral source: 16.7% among secondary/regional hospital referrals, 11.0% among lower-tier facility referrals (district, municipal, CHAG, polyclinic, private, health centre, and maternity home facilities combined, n = 356), 7.6% among self-presenting children, and 7.4% among tertiary referrals. Overall, 30.8% of children were classified as ETAT emergencies on arrival, with case fatility rate of 21.6%. The three most common diagnostic domains were respiratory conditions (17.2%), blood and haematological disorders (17.0%), and digestive presentations (16.4%). Inpatient mortality was highest in neoplastic disease (33.3%, n = 30) and circulatory presentations (31.0%, n = 29). In the primary multivariable analysis (n = 613, 51 events; events-per-variable ratio 4.2), no referral tier was independently associated with inpatient mortality after adjustment. Referral from secondary/regional hospitals showed a borderline non-significant association (adjusted odds ratio 3.09, 95% CI 0.96 to 9.90, p = 0.058). School going children (60-119 months) had higher odds of inpatient death than infants (adjusted odds ratio 5.56, 95% CI 1.16 to 26.53, p = 0.032), as did adolescents (adjusted odds ratio 10.01, 95% CI 2.15 to 46.69, p = 0.003). ETAT emergency category and lower socioeconomic status were not independently significant in this model. A pre-specified sensitivity analysis using the full analytic cohort (n = 674, events-per-variable ratio 6.7) with collapsed referral categories did not confirm any referral tier association; ETAT emergency category and lower SES were independently associated in the sensitivity model. All multivariable estimates should be regarded as exploratory. This prospective cohort provides simultaneous characterisation of referral patterns, ETAT triage acuity, diagnostic case mix, and inpatient mortality at a national tertiary paediatric emergency unit in West Africa. The referral-mortality gradient and high ETAT emergency category proportion document the severity of illness arriving through different referral pathways at this facility. The association between secondary/regional hospital referral and inpatient mortality is hypothesis-generating and requires replication in an adequately powered multicentre study before any service-level conclusions can be drawn.