A knowledge-guided agentic framework for mitigating patient-context ambiguity in health queries

Patients often submit short, underspecified queries to healthcare chatbots that lack the patient-specific information needed to determine an appropriate response. Although these queries may be linguistically clear, they can support multiple plausible answers depending on undisclosed factors such as symptoms, diagnoses, medications, allergies, or dietary restrictions. A language model answering such a query directly may therefore rely on unsupported assumptions about the patient. We introduce a knowledge-guided agentic framework for mitigating patient-context ambiguity before final response generation. The framework operates between the patient and an otherwise unchanged downstream language model. It interprets the initial query, uses a task-specific knowledge graph to construct a set of plausible hypotheses, identifies the missing patient-context variables needed to distinguish among them, and asks targeted follow-up questions. The original query and the acquired context are then combined into a clarified prompt for the downstream model. We evaluated the framework across five language models using two controlled ambiguity-mitigation benchmarks: diagnosis retrieval from 1,034 symptom queries with clinically relevant evidence systematically masked, and dietary-safety classification from 487 queries with decisive health context omitted. The framework was compared with direct answering of the underspecified query and with rephrasing the same query without acquiring new patient information. In diagnosis retrieval, it increased overall exact Top-1 accuracy by at least 57.1 percentage points and selective exact Recall@5 by at least 77.7 percentage points across the five evaluated models compared with direct prompting. In dietary-safety classification, it improved accuracy across all five models and achieved the highest Matthews correlation coefficient for four...

When Clean Signals Are Not Enough: Detecting Structural Ambiguity for Safe Wearable Stress Classification

Wearable stress classifiers can achieve strong average performance while failing completely for a particular individual. On WESAD, a Random Forest reaches 93.0% mean accuracy yet yields F1 = 0 for Subject 14, whose cross-signal coupling weakens near stress onset. We call this structural ambiguity: individually plausible physiological channels form an inter-signal pattern that is poorly supported by the person's non-stress reference. We introduce the Individual Conformal Coupling Monitor (ICCM), a lightweight and transparent pre-inference monitor that quantifies subject-specific coupling divergence and routes each window to classify, defer, or abstain without retraining the downstream classifier. Across WESAD (N = 15) and Stress-Predict (N = 35), full-cohort Pearson associations between ambiguity and accuracy are negative (r = -0.607, p = 0.016; r = -0.412, p = 0.014). Robustness analyses temper this finding: rank correlations are not significant, and the WESAD association disappears when Subject 14 is removed. ICCM changes false-positive counts from 29 to 27 and 94 to 92, although neither paired change is significant. It withholds 3 of Subject 14's 21 stress windows but does not repair the missed-stress failure. These results position ICCM as an interpretable signal of unsupported physiology and individual failure, rather than a stand-alone safety guarantee.

GoT-CD: Graph-of-Thoughts Causal Discovery and the Fragility of Post-hoc Path-Specific Fairness Audits

Causal discovery recovers directed structure from observational data and is increasingly used in clinical settings to support mechanism reasoning and fairness audits of predictive models. Path-specific counterfactual fairness asks whether a protected attribute influences an outcome through illegitimate pathways, but these estimands are defined relative to a supplied causal graph and therefore inherit whatever errors the discovery step introduces. Discovery methods are routinely scored on aggregate structural metrics that weight all edges equally, and no established evaluation asks whether the specific pathway an audit depends on survives discovery---or what the audit reports when that pathway is missing. Here we show that full-graph Graph-of-Thoughts reasoning yields acyclic discovered graphs that are structurally competitive with large language model (LLM) baselines, yet that structural fidelity alone does not guarantee fairness-faithful audits. We introduce GoT-CD, in which the reasoning unit is a complete candidate edge set: multiple graphs are generated in parallel, scored by a deterministic validity function, and merged under a hard union constraint that forbids invented edges, with greedy projection enforcing a DAG before commitment. GoT-CD returns a valid DAG on all five reported benchmarks and achieves the best DAG-valid F1 score among LLM methods on Asia, Alzheimer's, and COVID-Respiratory datasets. On an Alzheimer's benchmark with known unfair path, a post-hoc path-specific audit shows that five of eight discovered graphs recover no path from the sensitive attribute to the outcome and therefore report a null overall effect while mediated effects persist, necessitating downstream path-specific fairness analysis along with structural discovery.

FairDiffuseVQVAE: Sampling-Time Fairness in Tabular Diffusion via Conditional Refinement of Vector-Quantized Latents

Synthetic tabular data is increasingly used in privacy-preserving data sharing, data augmentation, and to mitigate downstream classifier bias. State-of-the-art tabular diffusion models such as TabDDPM and TabSyn achieve excellent distributional fidelity but offer no mechanism for fairness; conversely, fairness-aware tabular generators (DECAF, FairTGAN, FairTabDDPM) impose explicit fairness penalties at training time, yielding modest fairness gains at substantial cost to either sample quality or downstream utility. We introduce FairDiffuseVQVAE, a two-stage architecture that decouples fidelity from fairness: a vector-quantized autoencoder with a row-level discriminator (Stage~1, no fairness terms) is followed by a DiffuseVAE-style continuous diffusion refiner that conditions on both the Stage-1 reconstruction and the protected attribute via classifier-free guidance (Stage~2). Fairness emerges as a property of the sampling distribution -- uniform sampling of the protected attribute at inference time enforces demographic parity by construction, rather than from competing loss terms. On the Adult, Bank and COMPAS datasets, FairDiffuseVQVAE achieves the highest mean Demographic Parity Ratio ($0.702$, $+47\%$ over FairTabDDPM) and Equalized Odds Ratio ($0.686$, $+100\%$). It also attains the lowest mean pair-wise correlation error ($0.034$) of any published method, while explicitly trading $\sim$$15$ AUC points for these fairness gains.

From Sounds to Scenes: A Benchmark for Evaluating Context-Aware Auditory Scene Understanding in Large Audio Language Models

Recent Large Audio Language Models (LALMs) have achieved remarkable progress in audio perceptual tasks across individual acoustic layers, including speech, sound, and music. However, existing benchmarks predominantly evaluate these layers in isolation, overlooking the complex contextual relationships that arise when multiple acoustic sources co-occur in real-world auditory scenes. Real-world auditory interpretation requires Context-Aware Auditory Scene Understanding (CASU): the ability to comprehend the holistic scene by integrating sound layers. To evaluate this capability, we introduce the CASU benchmark, which assesses whether Audio LLMs can interpret auditory scenes composed of speech, acoustic events (e.g., announcements), and background environments (e.g., traffic), and reason about the logical relationships between these layers. We propose a scalable pipeline for constructing time-accurate, semi-synthetic audio streams by composing real-world scene sounds with synthetic speech. Building on this data, we design four tasks that probe scene understanding: contextual question answering, entity extraction from the scene, speaker role inference, and counterfactual reasoning where scene is manipulated. Experiments across multiple LALMs demonstrate that effective auditory scene understanding requires integration over all auditory layers, rather than reliance on speech or sound alone, underscoring the necessity of CASU for advancing complex audio understanding in LALMs.

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

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.

Beyond AHI: An Interpretable Causal-Discovery-Guided Framework for Sleep Recovery in Connected Health

Objective sleep assessment relies on polysomnography (PSG), yet clinical impact is often better reflected in patient-reported outcomes (PROs) such as sleepiness and fatigue. Existing summary indices, including the Apnea-Hypopnea Index (AHI), provide limited insight into the multidomain physiology underlying functional recovery. We propose an interpretable, causal-discovery--guided framework for deriving a hierarchical Sleep Recovery Score (SRS) from multimodal PSG. Using two large population cohorts (MESA: n=1540; MrOS: n=825), we apply directed acyclic graph (DAG) learning to identify candidate physiological drivers spanning respiratory burden, hypoxic burden, sleep fragmentation, sleep architecture, and autonomic regulation. Although derived from clinical PSG, these domains map naturally to sensing streams increasingly available in connected health technologies, including wearable ECG, oximetry, and sleep-stage estimation devices. To preserve mechanistic plausibility, we introduce a two-stage screening process that combines physiology-based constraints with constrained LLM-assisted auditing to identify and remove structural confounders and construct-overlapping variables. Across cohorts, these five domains emerge as recurrent physiological domains associated with recovery, and the resulting SRS shows up to 2.5$\times$ stronger alignment with perceived recovery than AHI. By linking multimodal sleep physiology to patient-centered outcomes through an interpretable, bias-aware, and domain structured framework, this work provides a practical foundation for recovery modeling across both clinical sleep studies and emerging smart and connected health settings.

AP-GRPO: Anchor-Gated Phonetic Alignment with Policy Optimization for Pathological Speech Reconstruction

Pathological speech from patients with neurodegenerative and neuromotor disorders is often acoustically distorted and linguistically fragmented, making pathological speech reconstruction necessary to recover intended textual content from distorted and incomplete speech recordings. Crucially, such recordings are rarely uniformly degraded: some words or short phrases remain reliable and can serve as audible anchors for reconstructing the corrupted surrounding content. We introduce Anchor-gated Phonetic Group Relative Policy Optimization (AP-GRPO), a GRPO framework with phonetic reward that aligns speech language models (SLMs) through audible-anchor preservation and inter-anchor phonetic compatibility to the original speech signal. AP-GRPO consists of: (i) an anchor-gated reward that matches reliable audible anchors in clear regions; and (ii) an inter-anchor phonetic alignment reward that evaluates whether recovered contents are phonetically supported by the corresponding corrupted inter-anchor speech span. Across four disease conditions, AP-GRPO improves faithful speech reconstruction, and the learned anchor constraint automatically adapts to each condition and thus reveals interpretable disease-specific profiles: conditions with severe articulatory degradation require stronger anchor enforcement, whereas milder impairment or linguistically impaired conditions rely more on phonetic alignment for inter-anchor recovery.

Can the Environment Speak for Itself? $T^{2}$-GRPO: A Turn-Trajectory Group Relative Policy Optimization for Caregiver Agents

Optimizing large language models (LLMs) for long-horizon caregiver agents requires balancing delayed task objectives with immediate environment dynamics, such as patient distress and resistance. In dementia care, this balance is especially difficult: trajectory level rewards are too sparse for turn level credit assignment, while external LLM-based evaluators are costly and can misread fragmented or indirect patient responses. To address this issue, we propose \textbf{T}urn-\textbf{T}rajectory \textbf{G}roup \textbf{R}elative \textbf{P}olicy \textbf{O}ptimization (\textbf{T$^{2}$-GRPO}), a framework that decouples caregiver RL into two normalized reward horizons and enforces safety through a binary hard veto. $T^2$-GRPO derives dense turn-level rewards directly from environment state transitions, measuring changes in patient distress and resistance from a frozen dementia patient simulator. These environment-grounded rewards are combined with trajectory-level evaluations through independent centered-rank normalization, which preserves heterogeneous reward signals and mitigates reward collapse. Extensive experiments on dementia caregivers show that T $^{2}$-GRPO outperforms competitive baselines, indicating a substantial improvement for emotionally sensitive caregiver scenarios that effectively handles immediate patient feedback, long-term care outcomes, and safety constraints.

Personalized Digital Health Modeling with Adaptive Support Users

Personalized models are essential in digital health because individuals exhibit substantial physiological and behavioral heterogeneity. Yet personalization is limited by scarce and noisy user-specific data. Most existing methods rely on population pretraining or data from similar users only, which can lead to biased transfer and weak generalization. We propose a unified personalization framework that trains a personal model using adaptively weighted support users, including both similar and dissimilar individuals. The objective integrates personal loss, similarity-weighted transfer from similar users, and contrastive regularization from dissimilar users to suppress misleading correlations. An iterative optimization algorithm jointly updates model parameters and user similarity weights. Experiments on six tasks across four real-world digital health datasets show consistent improvements over population and personalized baselines. The method achieves up to 10% lower RMSE on large-scale datasets and approximately 25% lower RMSE in low-data settings. The learned adaptive weights improve data efficiency and provide interpretable guidance for targeted data selection.