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To date, the most common approach for radiology deep learning pipelines is the use of end-to-end 3D networks based on models pre-trained on other tasks, followed by fine-tuning on the task at hand. In contrast, adjacent medical fields such as pathology, which focus on 2D images, have effectively adopted task-agnostic foundational models based on self-supervised learning (SSL), combined with weakly-supervised deep learning (DL). However, the field of radiology still lacks task-agnostic representation models due to the computational and data demands of 3D imaging and the anatomical complexity inherent to radiology scans. To address this gap, we propose CLEAR, a framework for radiology images that uses extracted embeddings from 2D slices along with attention-based aggregation for efficiently predicting clinical endpoints. As part of this framework, we introduce lesion-enhanced contrastive learning (LeCL), a novel approach to obtain visual representations driven by abnormalities in 2D axial slices across different locations of the CT scans. Specifically, we trained single-domain contrastive learning approaches using three different architectures: Vision Transformers, Vision State Space Models and Gated Convolutional Neural Networks. We evaluate our approach across three clinical tasks: tumor lesion location, lung disease detection, and patient staging, benchmarking against four state-of-the-art foundation models, including BiomedCLIP. Our findings demonstrate that CLEAR using representations learned through LeCL, outperforms existing foundation models, while being substantially more compute- and data-efficient.

MRI and CT are essential clinical cross-sectional imaging techniques for diagnosing complex conditions. However, large 3D datasets with annotations for deep learning are scarce. While methods like DINOv2 are encouraging for 2D image analysis, these methods have not been applied to 3D medical images. Furthermore, deep learning models often lack explainability due to their "black-box" nature. This study aims to extend 2D self-supervised models, specifically DINOv2, to 3D medical imaging while evaluating their potential for explainable outcomes. We introduce the Medical Slice Transformer (MST) framework to adapt 2D self-supervised models for 3D medical image analysis. MST combines a Transformer architecture with a 2D feature extractor, i.e., DINOv2. We evaluate its diagnostic performance against a 3D convolutional neural network (3D ResNet) across three clinical datasets: breast MRI (651 patients), chest CT (722 patients), and knee MRI (1199 patients). Both methods were tested for diagnosing breast cancer, predicting lung nodule dignity, and detecting meniscus tears. Diagnostic performance was assessed by calculating the Area Under the Receiver Operating Characteristic Curve (AUC). Explainability was evaluated through a radiologist's qualitative comparison of saliency maps based on slice and lesion correctness. P-values were calculated using Delong's test. MST achieved higher AUC values compared to ResNet across all three datasets: breast (0.94$\pm$0.01 vs. 0.91$\pm$0.02, P=0.02), chest (0.95$\pm$0.01 vs. 0.92$\pm$0.02, P=0.13), and knee (0.85$\pm$0.04 vs. 0.69$\pm$0.05, P=0.001). Saliency maps were consistently more precise and anatomically correct for MST than for ResNet. Self-supervised 2D models like DINOv2 can be effectively adapted for 3D medical imaging using MST, offering enhanced diagnostic accuracy and explainability compared to convolutional neural networks.

Representation learning of pathology whole-slide images(WSIs) has primarily relied on weak supervision with Multiple Instance Learning (MIL). This approach leads to slide representations highly tailored to a specific clinical task. Self-supervised learning (SSL) has been successfully applied to train histopathology foundation models (FMs) for patch embedding generation. However, generating patient or slide level embeddings remains challenging. Existing approaches for slide representation learning extend the principles of SSL from patch level learning to entire slides by aligning different augmentations of the slide or by utilizing multimodal data. By integrating tile embeddings from multiple FMs, we propose a new single modality SSL method in feature space that generates useful slide representations. Our contrastive pretraining strategy, called COBRA, employs multiple FMs and an architecture based on Mamba-2. COBRA exceeds performance of state-of-the-art slide encoders on four different public Clinical Protemic Tumor Analysis Consortium (CPTAC) cohorts on average by at least +4.5% AUC, despite only being pretrained on 3048 WSIs from The Cancer Genome Atlas (TCGA). Additionally, COBRA is readily compatible at inference time with previously unseen feature extractors. Code available at https://github.com/KatherLab/COBRA.

The aggressiveness of prostate cancer, the most common cancer in men worldwide, is primarily assessed based on histopathological data using the Gleason scoring system. While artificial intelligence (AI) has shown promise in accurately predicting Gleason scores, these predictions often lack inherent explainability, potentially leading to distrust in human-machine interactions. To address this issue, we introduce a novel dataset of 1,015 tissue microarray core images, annotated by an international group of 54 pathologists. The annotations provide detailed localized pattern descriptions for Gleason grading in line with international guidelines. Utilizing this dataset, we develop an inherently explainable AI system based on a U-Net architecture that provides predictions leveraging pathologists' terminology. This approach circumvents post-hoc explainability methods while maintaining or exceeding the performance of methods trained directly for Gleason pattern segmentation (Dice score: 0.713 $\pm$ 0.003 trained on explanations vs. 0.691 $\pm$ 0.010 trained on Gleason patterns). By employing soft labels during training, we capture the intrinsic uncertainty in the data, yielding strong results in Gleason pattern segmentation even in the context of high interobserver variability. With the release of this dataset, we aim to encourage further research into segmentation in medical tasks with high levels of subjectivity and to advance the understanding of pathologists' reasoning processes., Comment: 58 pages, 15 figures (incl. supplementary)

Artificial intelligence (AI) systems have substantially improved dermatologists' diagnostic accuracy for melanoma, with explainable AI (XAI) systems further enhancing clinicians' confidence and trust in AI-driven decisions. Despite these advancements, there remains a critical need for objective evaluation of how dermatologists engage with both AI and XAI tools. In this study, 76 dermatologists participated in a reader study, diagnosing 16 dermoscopic images of melanomas and nevi using an XAI system that provides detailed, domain-specific explanations. Eye-tracking technology was employed to assess their interactions. Diagnostic performance was compared with that of a standard AI system lacking explanatory features. Our findings reveal that XAI systems improved balanced diagnostic accuracy by 2.8 percentage points relative to standard AI. Moreover, diagnostic disagreements with AI/XAI systems and complex lesions were associated with elevated cognitive load, as evidenced by increased ocular fixations. These insights have significant implications for clinical practice, the design of AI tools for visual tasks, and the broader development of XAI in medical diagnostics.

Rare gynecological tumors (RGTs) present major clinical challenges due to their low incidence and heterogeneity. The lack of clear guidelines leads to suboptimal management and poor prognosis. Molecular tumor boards accelerate access to effective therapies by tailoring treatment based on biomarkers, beyond cancer type. Unstructured data that requires manual curation hinders efficient use of biomarker profiling for therapy matching. This study explores the use of large language models (LLMs) to construct digital twins for precision medicine in RGTs. Our proof-of-concept digital twin system integrates clinical and biomarker data from institutional and published cases (n=21) and literature-derived data (n=655 publications with n=404,265 patients) to create tailored treatment plans for metastatic uterine carcinosarcoma, identifying options potentially missed by traditional, single-source analysis. LLM-enabled digital twins efficiently model individual patient trajectories. Shifting to a biology-based rather than organ-based tumor definition enables personalized care that could advance RGT management and thus enhance patient outcomes., Comment: 20 pages, 2 figures, 3 tables, supplements, original article

Advancements in artificial intelligence have driven the development of numerous pathology foundation models capable of extracting clinically relevant information. However, there is currently limited literature independently evaluating these foundation models on truly external cohorts and clinically-relevant tasks to uncover adjustments for future improvements. In this study, we benchmarked 19 histopathology foundation models on 13 patient cohorts with 6,818 patients and 9,528 slides from lung, colorectal, gastric, and breast cancers. The models were evaluated on weakly-supervised tasks related to biomarkers, morphological properties, and prognostic outcomes. We show that a vision-language foundation model, CONCH, yielded the highest performance when compared to vision-only foundation models, with Virchow2 as close second. The experiments reveal that foundation models trained on distinct cohorts learn complementary features to predict the same label, and can be fused to outperform the current state of the art. An ensemble combining CONCH and Virchow2 predictions outperformed individual models in 55% of tasks, leveraging their complementary strengths in classification scenarios. Moreover, our findings suggest that data diversity outweighs data volume for foundation models. Our work highlights actionable adjustments to improve pathology foundation models.

Vision-language artificial intelligence models (VLMs) possess medical knowledge and can be employed in healthcare in numerous ways, including as image interpreters, virtual scribes, and general decision support systems. However, here, we demonstrate that current VLMs applied to medical tasks exhibit a fundamental security flaw: they can be attacked by prompt injection attacks, which can be used to output harmful information just by interacting with the VLM, without any access to its parameters. We performed a quantitative study to evaluate the vulnerabilities to these attacks in four state of the art VLMs which have been proposed to be of utility in healthcare: Claude 3 Opus, Claude 3.5 Sonnet, Reka Core, and GPT-4o. Using a set of N=297 attacks, we show that all of these models are susceptible. Specifically, we show that embedding sub-visual prompts in medical imaging data can cause the model to provide harmful output, and that these prompts are non-obvious to human observers. Thus, our study demonstrates a key vulnerability in medical VLMs which should be mitigated before widespread clinical adoption., Comment: 57 Pages, 5 Figures

Large language models (LLMs) often generate outdated or inaccurate information based on static training datasets. Retrieval augmented generation (RAG) mitigates this by integrating outside data sources. While previous RAG systems used pre-assembled, fixed databases with limited flexibility, we have developed Radiology RAG (RadioRAG), an end-to-end framework that retrieves data from authoritative radiologic online sources in real-time. We evaluate the diagnostic accuracy of various LLMs when answering radiology-specific questions with and without access to additional online information via RAG. Using 80 questions from the RSNA Case Collection across radiologic subspecialties and 24 additional expert-curated questions with reference standard answers, LLMs (GPT-3.5-turbo, GPT-4, Mistral-7B, Mixtral-8x7B, and Llama3 [8B and 70B]) were prompted with and without RadioRAG in a zero-shot inference scenario RadioRAG retrieved context-specific information from www.radiopaedia.org in real-time. Accuracy was investigated. Statistical analyses were performed using bootstrapping. The results were further compared with human performance. RadioRAG improved diagnostic accuracy across most LLMs, with relative accuracy increases ranging up to 54% for different LLMs. It matched or exceeded non-RAG models and the human radiologist in question answering across radiologic subspecialties, particularly in breast imaging and emergency radiology. However, the degree of improvement varied among models; GPT-3.5-turbo and Mixtral-8x7B-instruct-v0.1 saw notable gains, while Mistral-7B-instruct-v0.2 showed no improvement, highlighting variability in RadioRAG's effectiveness. LLMs benefit when provided access to domain-specific data beyond their training data. For radiology, RadioRAG establishes a robust framework that substantially improves diagnostic accuracy and factuality in radiological question answering.

Matching cancer patients to clinical trials is essential for advancing treatment and patient care. However, the inconsistent format of medical free text documents and complex trial eligibility criteria make this process extremely challenging and time-consuming for physicians. We investigated whether the entire trial matching process - from identifying relevant trials among 105,600 oncology-related clinical trials on clinicaltrials.gov to generating criterion-level eligibility matches - could be automated using Large Language Models (LLMs). Using GPT-4o and a set of 51 synthetic Electronic Health Records (EHRs), we demonstrate that our approach identifies relevant candidate trials in 93.3% of cases and achieves a preliminary accuracy of 88.0% when matching patient-level information at the criterion level against a baseline defined by human experts. Utilizing LLM feedback reveals that 39.3% criteria that were initially considered incorrect are either ambiguous or inaccurately annotated, leading to a total model accuracy of 92.7% after refining our human baseline. In summary, we present an end-to-end pipeline for clinical trial matching using LLMs, demonstrating high precision in screening and matching trials to individual patients, even outperforming the performance of qualified medical doctors. Our fully end-to-end pipeline can operate autonomously or with human supervision and is not restricted to oncology, offering a scalable solution for enhancing patient-trial matching in real-world settings., Comment: 149 pages, including Supplements. 3 Main Figures

Denoising diffusion models offer a promising approach to accelerating magnetic resonance imaging (MRI) and producing diagnostic-level images in an unsupervised manner. However, our study demonstrates that even tiny worst-case potential perturbations transferred from a surrogate model can cause these models to generate fake tissue structures that may mislead clinicians. The transferability of such worst-case perturbations indicates that the robustness of image reconstruction may be compromised due to MR system imperfections or other sources of noise. Moreover, at larger perturbation strengths, diffusion models exhibit Gaussian noise-like artifacts that are distinct from those observed in supervised models and are more challenging to detect. Our results highlight the vulnerability of current state-of-the-art diffusion-based reconstruction models to possible worst-case perturbations and underscore the need for further research to improve their robustness and reliability in clinical settings.

The Transformer model has been pivotal in advancing fields such as natural language processing, speech recognition, and computer vision. However, a critical limitation of this model is its quadratic computational and memory complexity relative to the sequence length, which constrains its application to longer sequences. This is especially crucial in medical imaging where high-resolution images can reach gigapixel scale. Efforts to address this issue have predominantely focused on complex techniques, such as decomposing the softmax operation integral to the Transformer's architecture. This paper addresses this quadratic computational complexity of Transformer models and introduces a remarkably simple and effective method that circumvents this issue by eliminating the softmax function from the attention mechanism and adopting a sequence normalization technique for the key, query, and value tokens. Coupled with a reordering of matrix multiplications this approach reduces the memory- and compute complexity to a linear scale. We evaluate this approach across various medical imaging datasets comprising fundoscopic, dermascopic, radiologic and histologic imaging data. Our findings highlight that these models exhibit a comparable performance to traditional transformer models, while efficiently handling longer sequences.

Multimodal artificial intelligence (AI) systems have the potential to enhance clinical decision-making by interpreting various types of medical data. However, the effectiveness of these models across all medical fields is uncertain. Each discipline presents unique challenges that need to be addressed for optimal performance. This complexity is further increased when attempting to integrate different fields into a single model. Here, we introduce an alternative approach to multimodal medical AI that utilizes the generalist capabilities of a large language model (LLM) as a central reasoning engine. This engine autonomously coordinates and deploys a set of specialized medical AI tools. These tools include text, radiology and histopathology image interpretation, genomic data processing, web searches, and document retrieval from medical guidelines. We validate our system across a series of clinical oncology scenarios that closely resemble typical patient care workflows. We show that the system has a high capability in employing appropriate tools (97%), drawing correct conclusions (93.6%), and providing complete (94%), and helpful (89.2%) recommendations for individual patient cases while consistently referencing relevant literature (82.5%) upon instruction. This work provides evidence that LLMs can effectively plan and execute domain-specific models to retrieve or synthesize new information when used as autonomous agents. This enables them to function as specialist, patient-tailored clinical assistants. It also simplifies regulatory compliance by allowing each component tool to be individually validated and approved. We believe, that our work can serve as a proof-of-concept for more advanced LLM-agents in the medical domain., Comment: 91 pages, 2 Figures

Medical image classification requires labeled, task-specific datasets which are used to train deep learning networks de novo, or to fine-tune foundation models. However, this process is computationally and technically demanding. In language processing, in-context learning provides an alternative, where models learn from within prompts, bypassing the need for parameter updates. Yet, in-context learning remains underexplored in medical image analysis. Here, we systematically evaluate the model Generative Pretrained Transformer 4 with Vision capabilities (GPT-4V) on cancer image processing with in-context learning on three cancer histopathology tasks of high importance: Classification of tissue subtypes in colorectal cancer, colon polyp subtyping and breast tumor detection in lymph node sections. Our results show that in-context learning is sufficient to match or even outperform specialized neural networks trained for particular tasks, while only requiring a minimal number of samples. In summary, this study demonstrates that large vision language models trained on non-domain specific data can be applied out-of-the box to solve medical image-processing tasks in histopathology. This democratizes access of generalist AI models to medical experts without technical background especially for areas where annotated data is scarce., Comment: 40 pages, 5 figures

Deep Learning models have been successfully utilized to extract clinically actionable insights from routinely available histology data. Generally, these models require annotations performed by clinicians, which are scarce and costly to generate. The emergence of self-supervised learning (SSL) methods remove this barrier, allowing for large-scale analyses on non-annotated data. However, recent SSL approaches apply increasingly expansive model architectures and larger datasets, causing the rapid escalation of data volumes, hardware prerequisites, and overall expenses, limiting access to these resources to few institutions. Therefore, we investigated the complexity of contrastive SSL in computational pathology in relation to classification performance with the utilization of consumer-grade hardware. Specifically, we analyzed the effects of adaptations in data volume, architecture, and algorithms on downstream classification tasks, emphasizing their impact on computational resources. We trained breast cancer foundation models on a large public patient cohort and validated them on various downstream classification tasks in a weakly supervised manner on two external public patient cohorts. Our experiments demonstrate that we can improve downstream classification performance whilst reducing SSL training duration by 90%. In summary, we propose a set of adaptations which enable the utilization of SSL in computational pathology in non-resource abundant environments., Comment: Submitted to MICCAI 2024

Deep Learning (DL) can predict biomarkers directly from digitized cancer histology in a weakly-supervised setting. Recently, the prediction of continuous biomarkers through regression-based DL has seen an increasing interest. Nonetheless, clinical decision making often requires a categorical outcome. Consequently, we developed a weakly-supervised joint multi-task Transformer architecture which has been trained and evaluated on four public patient cohorts for the prediction of two key predictive biomarkers, microsatellite instability (MSI) and homologous recombination deficiency (HRD), trained with auxiliary regression tasks related to the tumor microenvironment. Moreover, we perform a comprehensive benchmark of 16 approaches of task balancing for weakly-supervised joint multi-task learning in computational pathology. Using our novel approach, we improve over the state-of-the-art area under the receiver operating characteristic by +7.7% and +4.1%, as well as yielding better clustering of latent embeddings by +8% and +5% for the prediction of MSI and HRD in external cohorts, respectively.

AI models present a wide range of applications in the field of medicine. However, achieving optimal performance requires access to extensive healthcare data, which is often not readily available. Furthermore, the imperative to preserve patient privacy restricts patient data sharing with third parties and even within institutes. Recently, generative AI models have been gaining traction for facilitating open-data sharing by proposing synthetic data as surrogates of real patient data. Despite the promise, these models are susceptible to patient data memorization, where models generate patient data copies instead of novel synthetic samples. Considering the importance of the problem, it has received little attention in the medical imaging community. To this end, we assess memorization in unconditional latent diffusion models. We train 2D and 3D latent diffusion models on CT, MR, and X-ray datasets for synthetic data generation. Afterwards, we detect the amount of training data memorized utilizing our self-supervised approach and further investigate various factors that can influence memorization. Our findings show a surprisingly high degree of patient data memorization across all datasets, with approximately 40.9% of patient data being memorized and 78.5% of synthetic samples identified as patient data copies on average in our experiments. Further analyses reveal that using augmentation strategies during training can reduce memorization while over-training the models can enhance it. Although increasing the dataset size does not reduce memorization and might even enhance it, it does lower the probability of a synthetic sample being a patient data copy. Collectively, our results emphasize the importance of carefully training generative models on private medical imaging datasets, and examining the synthetic data to ensure patient privacy before sharing it for medical research and applications.

Background: Recent advancements in large language models (LLMs) offer potential benefits in healthcare, particularly in processing extensive patient records. However, existing benchmarks do not fully assess LLMs' capability in handling real-world, lengthy clinical data. Methods: We present the LongHealth benchmark, comprising 20 detailed fictional patient cases across various diseases, with each case containing 5,090 to 6,754 words. The benchmark challenges LLMs with 400 multiple-choice questions in three categories: information extraction, negation, and sorting, challenging LLMs to extract and interpret information from large clinical documents. Results: We evaluated nine open-source LLMs with a minimum of 16,000 tokens and also included OpenAI's proprietary and cost-efficient GPT-3.5 Turbo for comparison. The highest accuracy was observed for Mixtral-8x7B-Instruct-v0.1, particularly in tasks focused on information retrieval from single and multiple patient documents. However, all models struggled significantly in tasks requiring the identification of missing information, highlighting a critical area for improvement in clinical data interpretation. Conclusion: While LLMs show considerable potential for processing long clinical documents, their current accuracy levels are insufficient for reliable clinical use, especially in scenarios requiring the identification of missing information. The LongHealth benchmark provides a more realistic assessment of LLMs in a healthcare setting and highlights the need for further model refinement for safe and effective clinical application. We make the benchmark and evaluation code publicly available., Comment: 11 pages, 3 figures, 5 tables

Hematoxylin- and eosin (H&E) stained whole-slide images (WSIs) are the foundation of diagnosis of cancer. In recent years, development of deep learning-based methods in computational pathology enabled the prediction of biomarkers directly from WSIs. However, accurately linking tissue phenotype to biomarkers at scale remains a crucial challenge for democratizing complex biomarkers in precision oncology. This protocol describes a practical workflow for solid tumor associative modeling in pathology (STAMP), enabling prediction of biomarkers directly from WSIs using deep learning. The STAMP workflow is biomarker agnostic and allows for genetic- and clinicopathologic tabular data to be included as an additional input, together with histopathology images. The protocol consists of five main stages which have been successfully applied to various research problems: formal problem definition, data preprocessing, modeling, evaluation and clinical translation. The STAMP workflow differentiates itself through its focus on serving as a collaborative framework that can be used by clinicians and engineers alike for setting up research projects in the field of computational pathology. As an example task, we applied STAMP to the prediction of microsatellite instability (MSI) status in colorectal cancer, showing accurate performance for the identification of MSI-high tumors. Moreover, we provide an open-source codebase which has been deployed at several hospitals across the globe to set up computational pathology workflows. The STAMP workflow requires one workday of hands-on computational execution and basic command line knowledge.

Weakly supervised whole slide image classification is a key task in computational pathology, which involves predicting a slide-level label from a set of image patches constituting the slide. Constructing models to solve this task involves multiple design choices, often made without robust empirical or conclusive theoretical justification. To address this, we conduct a comprehensive benchmarking of feature extractors to answer three critical questions: 1) Is stain normalisation still a necessary preprocessing step? 2) Which feature extractors are best for downstream slide-level classification? 3) How does magnification affect downstream performance? Our study constitutes the most comprehensive evaluation of publicly available pathology feature extractors to date, involving more than 10,000 training runs across 14 feature extractors, 9 tasks, 5 datasets, 3 downstream architectures, 2 levels of magnification, and various preprocessing setups. Our findings challenge existing assumptions: 1) We observe empirically, and by analysing the latent space, that skipping stain normalisation and image augmentations does not degrade performance, while significantly reducing memory and computational demands. 2) We develop a novel evaluation metric to compare relative downstream performance, and show that the choice of feature extractor is the most consequential factor for downstream performance. 3) We find that lower-magnification slides are sufficient for accurate slide-level classification. Contrary to previous patch-level benchmarking studies, our approach emphasises clinical relevance by focusing on slide-level biomarker prediction tasks in a weakly supervised setting with external validation cohorts. Our findings stand to streamline digital pathology workflows by minimising preprocessing needs and informing the selection of feature extractors., Comment: For the conference version see: arXiv:2311.11772v4. For the longer journal version with additional experiments see arXiv:2311.11772v5

Detecting misleading patterns in automated diagnostic assistance systems, such as those powered by Artificial Intelligence, is critical to ensuring their reliability, particularly in healthcare. Current techniques for evaluating deep learning models cannot visualize confounding factors at a diagnostic level. Here, we propose a self-conditioned diffusion model termed DiffChest and train it on a dataset of 515,704 chest radiographs from 194,956 patients from multiple healthcare centers in the United States and Europe. DiffChest explains classifications on a patient-specific level and visualizes the confounding factors that may mislead the model. We found high inter-reader agreement when evaluating DiffChest's capability to identify treatment-related confounders, with Fleiss' Kappa values of 0.8 or higher across most imaging findings. Confounders were accurately captured with 11.1% to 100% prevalence rates. Furthermore, our pretraining process optimized the model to capture the most relevant information from the input radiographs. DiffChest achieved excellent diagnostic accuracy when diagnosing 11 chest conditions, such as pleural effusion and cardiac insufficiency, and at least sufficient diagnostic accuracy for the remaining conditions. Our findings highlight the potential of pretraining based on diffusion models in medical image classification, specifically in providing insights into confounding factors and model robustness.

Large language models (LLMs) have broad medical knowledge and can reason about medical information across many domains, holding promising potential for diverse medical applications in the near future. In this study, we demonstrate a concerning vulnerability of LLMs in medicine. Through targeted manipulation of just 1.1% of the model's weights, we can deliberately inject an incorrect biomedical fact. The erroneous information is then propagated in the model's output, whilst its performance on other biomedical tasks remains intact. We validate our findings in a set of 1,038 incorrect biomedical facts. This peculiar susceptibility raises serious security and trustworthiness concerns for the application of LLMs in healthcare settings. It accentuates the need for robust protective measures, thorough verification mechanisms, and stringent management of access to these models, ensuring their reliable and safe use in medical practice.