Online Reasoning Video Segmentation with Just-in-Time Digital Twins

Reasoning segmentation (RS) aims to identify and segment objects of interest based on implicit text queries. As such, RS is a catalyst for embodied AI agents, enabling them to interpret high-level commands without requiring explicit step-by-step guidance. However, current RS approaches rely heavily on the visual perception capabilities of multimodal large language models (LLMs), leading to several major limitations. First, they struggle with queries that require multiple steps of reasoning or those that involve complex spatial/temporal relationships. Second, they necessitate LLM fine-tuning, which may require frequent updates to maintain compatibility with contemporary LLMs and may increase risks of catastrophic forgetting during fine-tuning. Finally, being primarily designed for static images or offline video processing, they scale poorly to online video data. To address these limitations, we propose an agent framework that disentangles perception and reasoning for online video RS without LLM fine-tuning. Our innovation is the introduction of a just-in-time digital twin concept, where -- given an implicit query -- a LLM plans the construction of a low-level scene representation from high-level video using specialist vision models. We refer to this approach to creating a digital twin as "just-in-time" because the LLM planner will anticipate the need for specific information and only request this limited subset instead of always evaluating every specialist model. The LLM then performs reasoning on this digital twin representation to identify target objects. To evaluate our approach, we introduce a new comprehensive video reasoning segmentation benchmark comprising 200 videos with 895 implicit text queries. The benchmark spans three reasoning categories (semantic, spatial, and temporal) with three different reasoning chain complexity.

Operating Room Workflow Analysis via Reasoning Segmentation over Digital Twins

Analyzing operating room (OR) workflows to derive quantitative insights into OR efficiency is important for hospitals to maximize patient care and financial sustainability. Prior work on OR-level workflow analysis has relied on end-to-end deep neural networks. While these approaches work well in constrained settings, they are limited to the conditions specified at development time and do not offer the flexibility necessary to accommodate the OR workflow analysis needs of various OR scenarios (e.g., large academic center vs. rural provider) without data collection, annotation, and retraining. Reasoning segmentation (RS) based on foundation models offers this flexibility by enabling automated analysis of OR workflows from OR video feeds given only an implicit text query related to the objects of interest. Due to the reliance on large language model (LLM) fine-tuning, current RS approaches struggle with reasoning about semantic/spatial relationships and show limited generalization to OR video due to variations in visual characteristics and domain-specific terminology. To address these limitations, we first propose a novel digital twin (DT) representation that preserves both semantic and spatial relationships between the various OR components. Then, building on this foundation, we propose ORDiRS (Operating Room Digital twin representation for Reasoning Segmentation), an LLM-tuning-free RS framework that reformulates RS into a "reason-retrieval-synthesize" paradigm. Finally, we present ORDiRS-Agent, an LLM-based agent that decomposes OR workflow analysis queries into manageable RS sub-queries and generates responses by combining detailed textual explanations with supporting visual evidence from RS. Experimental results on both an in-house and a public OR dataset demonstrate that our ORDiRS achieves a cIoU improvement of 6.12%-9.74% compared to the existing state-of-the-arts.

Detecting Dataset Bias in Medical AI: A Generalized and Modality-Agnostic Auditing Framework

Data-driven AI is establishing itself at the center of evidence-based medicine. However, reports of shortcomings and unexpected behavior are growing due to AI's reliance on association-based learning. A major reason for this behavior: latent bias in machine learning datasets can be amplified during training and/or hidden during testing. We present a data modality-agnostic auditing framework for generating targeted hypotheses about sources of bias which we refer to as Generalized Attribute Utility and Detectability-Induced bias Testing (G-AUDIT) for datasets. Our method examines the relationship between task-level annotations and data properties including protected attributes (e.g., race, age, sex) and environment and acquisition characteristics (e.g., clinical site, imaging protocols). G-AUDIT automatically quantifies the extent to which the observed data attributes may enable shortcut learning, or in the case of testing data, hide predictions made based on spurious associations. We demonstrate the broad applicability and value of our method by analyzing large-scale medical datasets for three distinct modalities and learning tasks: skin lesion classification in images, stigmatizing language classification in Electronic Health Records (EHR), and mortality prediction for ICU tabular data. In each setting, G-AUDIT successfully identifies subtle biases commonly overlooked by traditional qualitative methods that focus primarily on social and ethical objectives, underscoring its practical value in exposing dataset-level risks and supporting the downstream development of reliable AI systems. Our method paves the way for achieving deeper understanding of machine learning datasets throughout the AI development life-cycle from initial prototyping all the way to regulation, and creates opportunities to reduce model bias, enabling safer and more trustworthy AI systems.

A Causal Framework for Aligning Image Quality Metrics and Deep Neural Network Robustness

Image quality plays an important role in the performance of deep neural networks (DNNs) and DNNs have been widely shown to exhibit sensitivity to changes in imaging conditions. Large-scale datasets often contain images under a wide range of conditions prompting a need to quantify and understand their underlying quality distribution in order to better characterize DNN performance and robustness. Aligning the sensitivities of image quality metrics and DNNs ensures that estimates of quality can act as proxies for image/dataset difficulty independent of the task models trained/evaluated on the data. Conventional image quality assessment (IQA) seeks to measure and align quality relative to human perceptual judgments, but here we seek a quality measure that is not only sensitive to imaging conditions but also well-aligned with DNN sensitivities. We first ask whether conventional IQA metrics are also informative of DNN performance. In order to answer this question, we reframe IQA from a causal perspective and examine conditions under which quality metrics are predictive of DNN performance. We show theoretically and empirically that current IQA metrics are weak predictors of DNN performance in the context of classification. We then use our causal framework to provide an alternative formulation and a new image quality metric that is more strongly correlated with DNN performance and can act as a prior on performance without training new task models. Our approach provides a means to directly estimate the quality distribution of large-scale image datasets towards characterizing the relationship between dataset composition and DNN performance.

An Intrinsically Explainable Approach to Detecting Vertebral Compression Fractures in CT Scans via Neurosymbolic Modeling

Vertebral compression fractures (VCFs) are a common and potentially serious consequence of osteoporosis. Yet, they often remain undiagnosed. Opportunistic screening, which involves automated analysis of medical imaging data acquired primarily for other purposes, is a cost-effective method to identify undiagnosed VCFs. In high-stakes scenarios like opportunistic medical diagnosis, model interpretability is a key factor for the adoption of AI recommendations. Rule-based methods are inherently explainable and closely align with clinical guidelines, but they are not immediately applicable to high-dimensional data such as CT scans. To address this gap, we introduce a neurosymbolic approach for VCF detection in CT volumes. The proposed model combines deep learning (DL) for vertebral segmentation with a shape-based algorithm (SBA) that analyzes vertebral height distributions in salient anatomical regions. This allows for the definition of a rule set over the height distributions to detect VCFs. Evaluation of VerSe19 dataset shows that our method achieves an accuracy of 96% and a sensitivity of 91% in VCF detection. In comparison, a black box model, DenseNet, achieved an accuracy of 95% and sensitivity of 91% in the same dataset. Our results demonstrate that our intrinsically explainable approach can match or surpass the performance of black box deep neural networks while providing additional insights into why a prediction was made. This transparency can enhance clinician's trust thus, supporting more informed decision-making in VCF diagnosis and treatment planning.

Memorizing SAM: 3D Medical Segment Anything Model with Memorizing Transformer

Segment Anything Models (SAMs) have gained increasing attention in medical image analysis due to their zero-shot generalization capability in segmenting objects of unseen classes and domains when provided with appropriate user prompts. Addressing this performance gap is important to fully leverage the pre-trained weights of SAMs, particularly in the domain of volumetric medical image segmentation, where accuracy is important but well-annotated 3D medical data for fine-tuning is limited. In this work, we investigate whether introducing the memory mechanism as a plug-in, specifically the ability to memorize and recall internal representations of past inputs, can improve the performance of SAM with limited computation cost. To this end, we propose Memorizing SAM, a novel 3D SAM architecture incorporating a memory Transformer as a plug-in. Unlike conventional memorizing Transformers that save the internal representation during training or inference, our Memorizing SAM utilizes existing highly accurate internal representation as the memory source to ensure the quality of memory. We evaluate the performance of Memorizing SAM in 33 categories from the TotalSegmentator dataset, which indicates that Memorizing SAM can outperform state-of-the-art 3D SAM variant i.e., FastSAM3D with an average Dice increase of 11.36% at the cost of only 4.38 millisecond increase in inference time. The source code is publicly available at https://github.com/swedfr/memorizingSAM

Intelligent Control of Robotic X-ray Devices using a Language-promptable Digital Twin

Natural language offers a convenient, flexible interface for controlling robotic C-arm X-ray systems, making advanced functionality and controls accessible. However, enabling language interfaces requires specialized AI models that interpret X-ray images to create a semantic representation for reasoning. The fixed outputs of such AI models limit the functionality of language controls. Incorporating flexible, language-aligned AI models prompted through language enables more versatile interfaces for diverse tasks and procedures. Using a language-aligned foundation model for X-ray image segmentation, our system continually updates a patient digital twin based on sparse reconstructions of desired anatomical structures. This supports autonomous capabilities such as visualization, patient-specific viewfinding, and automatic collimation from novel viewpoints, enabling commands 'Focus in on the lower lumbar vertebrae.' In a cadaver study, users visualized, localized, and collimated structures across the torso using verbal commands, achieving 84% end-to-end success. Post hoc analysis of randomly oriented images showed our patient digital twin could localize 35 commonly requested structures to within 51.68 mm, enabling localization and isolation from arbitrary orientations. Our results demonstrate how intelligent robotic X-ray systems can incorporate physicians' expressed intent directly. While existing foundation models for intra-operative X-ray analysis exhibit failure modes, as they improve, they can facilitate highly flexible, intelligent robotic C-arms.

Neural Finite-State Machines for Surgical Phase Recognition

Surgical phase recognition is essential for analyzing procedure-specific surgical videos. While recent transformer-based architectures have advanced sequence processing capabilities, they struggle with maintaining consistency across lengthy surgical procedures. Drawing inspiration from classical hidden Markov models' finite-state interpretations, we introduce the neural finite-state machine (NFSM) module, which bridges procedural understanding with deep learning approaches. NFSM combines procedure-level understanding with neural networks through global state embeddings, attention-based dynamic transition tables, and transition-aware training and inference mechanisms for offline and online applications. When integrated into our future-aware architecture, NFSM improves video-level accuracy, phase-level precision, recall, and Jaccard indices on Cholec80 datasets by 2.3, 3.2, 3.0, and 4.8 percentage points respectively. As an add-on module to existing state-of-the-art models like Surgformer, NFSM further enhances performance, demonstrating its complementary value. Extended experiments on non-surgical datasets validate NFSM's generalizability beyond surgical domains. Comprehensive experiments demonstrate that incorporating NSFM into deep learning frameworks enables more robust and consistent phase recognition across long procedural videos.

Causality-Driven Audits of Model Robustness

Robustness audits of deep neural networks (DNN) provide a means to uncover model sensitivities to the challenging real-world imaging conditions that significantly degrade DNN performance in-the-wild. Such conditions are often the result of the compounding of multiple factors inherent to the environment, sensor, or processing pipeline and may lead to complex image distortions that are not easily categorized. When robustness audits are limited to a set of pre-determined imaging effects or distortions, the results cannot be (easily) transferred to real-world conditions where image corruptions may be more complex or nuanced. To address this challenge, we present a new alternative robustness auditing method that uses causal inference to measure DNN sensitivities to the factors of the imaging process that cause complex distortions. Our approach uses causal models to explicitly encode assumptions about the domain-relevant factors and their interactions. Then, through extensive experiments on natural and rendered images across multiple vision tasks, we show that our approach reliably estimates causal effects of each factor on DNN performance using observational domain data. These causal effects directly tie DNN sensitivities to observable properties of the imaging pipeline in the domain of interest towards reducing the risk of unexpected DNN failures when deployed in that domain.

Towards Robust Algorithms for Surgical Phase Recognition via Digital Twin-based Scene Representation

Purpose: Surgical phase recognition (SPR) is an integral component of surgical data science, enabling high-level surgical analysis. End-to-end trained neural networks that predict surgical phase directly from videos have shown excellent performance on benchmarks. However, these models struggle with robustness due to non-causal associations in the training set, resulting in poor generalizability. Our goal is to improve model robustness to variations in the surgical videos by leveraging the digital twin (DT) paradigm -- an intermediary layer to separate high-level analysis (SPR) from low-level processing (geometric understanding). This approach takes advantage of the recent vision foundation models that ensure reliable low-level scene understanding to craft DT-based scene representations that support various high-level tasks. Methods: We present a DT-based framework for SPR from videos. The framework employs vision foundation models to extract representations. We embed the representation in place of raw video inputs in the state-of-the-art Surgformer model. The framework is trained on the Cholec80 dataset and evaluated on out-of-distribution (OOD) and corrupted test samples. Results: Contrary to the vulnerability of the baseline model, our framework demonstrates strong robustness on both OOD and corrupted samples, with a video-level accuracy of 51.1 on the challenging CRCD dataset, 96.0 on an internal robotics training dataset, and 64.4 on a highly corrupted Cholec80 test set. Conclusion: Our findings lend support to the thesis that DT-based scene representations are effective in enhancing model robustness. Future work will seek to improve the feature informativeness, automate feature extraction, and incorporate interpretability for a more comprehensive framework.