Unlocking In-Context Learning in Audio-Language Models from Decentralized Medical Audio

Clinical audio diagnosis in low-resource settings requires models that identify conditions from minimal examples without large annotated corpora. We propose Federated Self-Contextualization (FSC), a multimodal language model framework for in-context clinical audio diagnosis across federated hospital clients. FSC constructs pseudo-label episodes via unsupervised clustering of audio representations, bypassing scarce real diagnostic labels, and enables contextual reasoning from support-query pairs. Our progressive three-stage pipeline first aligns audio embeddings with the language model via caption-based pretraining, then adapts it for episodic in-context inference through federated optimization. At test time, given a small labeled support set, the model diagnoses an unseen query through multimodal reasoning. On held-out respiratory and cardiac conditions, FSC achieves 71.6% accuracy in 2-way 2-shot evaluation, outperforming audio-language baselines by over 9%.

VitalAgent: A Tool-Augmented Agent for Reactive and Proactive Physiological Monitoring over Wearable Health Data

Wearable devices enable continuous monitoring of physiological signals such as ECG and PPG, but existing mHealth systems are largely limited to task-specific prediction pipelines or reactive question answering over static summaries. They lack the ability to support temporal reasoning, persistent physiological context, and proactive monitoring over long-term signal streams. We propose VitalAgent, a tool-augmented agentic framework for ECG/PPG-based mHealth that supports both reactive question answering and proactive monitoring. VitalAgent is built on a longitudinal physiological memory and a tool-augmented reasoning interface that enables dynamic computation over raw signals. We further introduce VitalBench, a longitudinal physiological monitoring benchmark dataset comprising 1,862 QA pairs for reactive question answering and 90.2 hours of continuous ECG/PPG recordings for proactive monitoring, covering cardiac, physical activity, and stress-related tasks. Experiments demonstrate that VitalAgent achieves over 30% improvement over prompt-based and ReAct baselines in reactive evaluation and supports proactive alert monitoring over long-term physiological signals, highlighting the importance of dynamic tool use and long-term physiological monitoring.

Adaptive Test-Time Scaling for Zero-Shot Respiratory Audio Classification

Automated respiratory audio analysis promises scalable, non-invasive disease screening, yet progress is limited by scarce labeled data and costly expert annotation. Zero-shot inference eliminates task-specific supervision, but existing methods apply uniform computation to every input regardless of difficulty. We introduce TRIAGE, a tiered zero-shot framework that adaptively scales test-time compute by routing each audio sample through progressively richer reasoning stages: fast label-cosine scoring in a joint audio-text embedding space (Tier-L), structured matching with clinician-style descriptors (Tier-M), and retrieval-augmented large language model reasoning (Tier-H). A confidence-based router finalizes easy predictions early while allocating additional computation to ambiguous inputs, enabling nearly half of all samples to exit at the cheapest tier. Across nine respiratory classification tasks without task-specific training, TRIAGE achieves a mean AUROC of 0.744, outperforming prior zero-shot methods and matching or exceeding supervised baselines on multiple tasks. Our analysis show that test-time scaling concentrates gains where they matter: uncertain cases see up to 19% relative improvement while confident predictions remain unchanged at minimal cost.

Learning ECG Image Representations via Dual Physiological-Aware Alignments

Electrocardiograms (ECGs) are among the most widely used diagnostic tools for cardiovascular diseases, and a large amount of ECG data worldwide appears only in image form. However, most existing automated ECG analysis methods rely on access to raw signal recordings, limiting their applicability in real-world and resource-constrained settings. In this paper, we present ECG-Scan, a self-supervised framework for learning clinically generalized representations from ECG images through dual physiological-aware alignments: 1) Our approach optimizes image representation learning using multimodal contrastive alignment between image and gold-standard signal-text modalities. 2) We further integrate domain knowledge via soft-lead constraints, regularizing the reconstruction process and improving signal lead inter-consistency. Extensive benchmarking across multiple datasets and downstream tasks demonstrates that our image-based model achieves superior performance compared to existing image baselines and notably narrows the gap between ECG image and signal analysis. These results highlight the potential of self-supervised image modeling to unlock large-scale legacy ECG data and broaden access to automated cardiovascular diagnostics.

StethoLM: Audio Language Model for Cardiopulmonary Analysis Across Clinical Tasks

Listening to heart and lung sounds - auscultation - is one of the first and most fundamental steps in a clinical examination. Despite being fast and non-invasive, it demands years of experience to interpret subtle audio cues. Recent deep learning methods have made progress in automating cardiopulmonary sound analysis, yet most are restricted to simple classification and offer little clinical interpretability or decision support. We present StethoLM, the first audio-language model specialized for cardiopulmonary auscultation, capable of performing instruction-driven clinical tasks across the full spectrum of auscultation analysis. StethoLM integrates audio encoding with a medical language model backbone and is trained on StethoBench, a comprehensive benchmark comprising 77,027 instruction-response pairs synthesized from 16,125 labeled cardiopulmonary recordings spanning seven clinical task categories: binary classification, detection, reporting, reasoning, differential diagnosis, comparison, and location-based analysis. Through multi-stage training that combines supervised fine-tuning and direct preference optimization, StethoLM achieves substantial gains in performance and robustness on out-of-distribution data. Our work establishes a foundation for instruction-following AI systems in clinical auscultation.

UniPACT: A Multimodal Framework for Prognostic Question Answering on Raw ECG and Structured EHR

Accurate clinical prognosis requires synthesizing structured Electronic Health Records (EHRs) with real-time physiological signals like the Electrocardiogram (ECG). Large Language Models (LLMs) offer a powerful reasoning engine for this task but struggle to natively process these heterogeneous, non-textual data types. To address this, we propose UniPACT (Unified Prognostic Question Answering for Clinical Time-series), a unified framework for prognostic question answering that bridges this modality gap. UniPACT's core contribution is a structured prompting mechanism that converts numerical EHR data into semantically rich text. This textualized patient context is then fused with representations learned directly from raw ECG waveforms, enabling an LLM to reason over both modalities holistically. We evaluate UniPACT on the comprehensive MDS-ED benchmark, it achieves a state-of-the-art mean AUROC of 89.37% across a diverse set of prognostic tasks including diagnosis, deterioration, ICU admission, and mortality, outperforming specialized baselines. Further analysis demonstrates that our multimodal, multi-task approach is critical for performance and provides robustness in missing data scenarios.

Interpretable Multimodal Zero-Shot ECG Diagnosis via Structured Clinical Knowledge Alignment

Electrocardiogram (ECG) interpretation is essential for cardiovascular disease diagnosis, but current automated systems often struggle with transparency and generalization to unseen conditions. To address this, we introduce ZETA, a zero-shot multimodal framework designed for interpretable ECG diagnosis aligned with clinical workflows. ZETA uniquely compares ECG signals against structured positive and negative clinical observations, which are curated through an LLM-assisted, expert-validated process, thereby mimicking differential diagnosis. Our approach leverages a pre-trained multimodal model to align ECG and text embeddings without disease-specific fine-tuning. Empirical evaluations demonstrate ZETA's competitive zero-shot classification performance and, importantly, provide qualitative and quantitative evidence of enhanced interpretability, grounding predictions in specific, clinically relevant positive and negative diagnostic features. ZETA underscores the potential of aligning ECG analysis with structured clinical knowledge for building more transparent, generalizable, and trustworthy AI diagnostic systems. We will release the curated observation dataset and code to facilitate future research.

Helmsman: Autonomous Synthesis of Federated Learning Systems via Multi-Agent Collaboration

Federated Learning (FL) offers a powerful paradigm for training models on decentralized data, but its promise is often undermined by the immense complexity of designing and deploying robust systems. The need to select, combine, and tune strategies for multifaceted challenges like data heterogeneity and system constraints has become a critical bottleneck, resulting in brittle, bespoke solutions. To address this, we introduce Helmsman, a novel multi-agent system that automates the end-to-end synthesis of federated learning systems from high-level user specifications. It emulates a principled research and development workflow through three collaborative phases: (1) interactive human-in-the-loop planning to formulate a sound research plan, (2) modular code generation by supervised agent teams, and (3) a closed-loop of autonomous evaluation and refinement in a sandboxed simulation environment. To facilitate rigorous evaluation, we also introduce AgentFL-Bench, a new benchmark comprising 16 diverse tasks designed to assess the system-level generation capabilities of agentic systems in FL. Extensive experiments demonstrate that our approach generates solutions competitive with, and often superior to, established hand-crafted baselines. Our work represents a significant step towards the automated engineering of complex decentralized AI systems.

Unified Multi-task Learning for Voice-Based Detection of Diverse Clinical Conditions

Voice-based health assessment offers unprecedented opportunities for scalable, non-invasive disease screening, yet existing approaches typically focus on single conditions and fail to leverage the rich, multi-faceted information embedded in speech. We present MARVEL (Multi-task Acoustic Representations for Voice-based Health Analysis), a privacy-conscious multitask learning framework that simultaneously detects nine distinct neurological, respiratory, and voice disorders using only derived acoustic features, eliminating the need for raw audio transmission. Our dual-branch architecture employs specialized encoders with task-specific heads sharing a common acoustic backbone, enabling effective cross-condition knowledge transfer. Evaluated on the large-scale Bridge2AI-Voice v2.0 dataset, MARVEL achieves an overall AUROC of 0.78, with exceptional performance on neurological disorders (AUROC = 0.89), particularly for Alzheimer's disease/mild cognitive impairment (AUROC = 0.97). Our framework consistently outperforms single-modal baselines by 5-19% and surpasses state-of-the-art self-supervised models on 7 of 9 tasks, while correlation analysis reveals that the learned representations exhibit meaningful similarities with established acoustic features, indicating that the model's internal representations are consistent with clinically recognized acoustic patterns. By demonstrating that a single unified model can effectively screen for diverse conditions, this work establishes a foundation for deployable voice-based diagnostics in resource-constrained and remote healthcare settings.

Q-Heart: ECG Question Answering via Knowledge-Informed Multimodal LLMs

Electrocardiography (ECG) offers critical cardiovascular insights, such as identifying arrhythmias and myocardial ischemia, but enabling automated systems to answer complex clinical questions directly from ECG signals (ECG-QA) remains a significant challenge. Current approaches often lack robust multimodal reasoning capabilities or rely on generic architectures ill-suited for the nuances of physiological signals. We introduce Q-Heart, a novel multimodal framework designed to bridge this gap. Q-Heart leverages a powerful, adapted ECG encoder and integrates its representations with textual information via a specialized ECG-aware transformer-based mapping layer. Furthermore, Q-Heart leverages dynamic prompting and retrieval of relevant historical clinical reports to guide tuning the language model toward knowledge-aware ECG reasoning. Extensive evaluations on the benchmark ECG-QA dataset show Q-Heart achieves state-of-the-art performance, outperforming existing methods by a 4% improvement in exact match accuracy. Our work demonstrates the effectiveness of combining domain-specific architectural adaptations with knowledge-augmented LLM instruction tuning for complex physiological ECG analysis, paving the way for more capable and potentially interpretable clinical patient care systems.