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Autonomously improve a real artifact (code, training recipe, agent harness, data pipeline, prompt) against an objective and an evaluator, using Hypothesis Tree Refinement (HTR) from the Arbor paper. Use this whenever someone wants to iteratively optimize something over many experiments without overfitting — e.g. "get my model's eval score up", "improve this agent/harness", "tune this pipeline", "beat the baseline on this benchmark", "run a search over approaches and keep the best", "do an MLE-bench / Kaggle-style optimization", or any long-horizon "make this artifact better and don't just memorize the dev set" task. Trigger it even when the user doesn't say "Arbor" or "hypothesis tree" but describes repeated experiment-and-evaluate loops, branching exploration of competing ideas, or worries about a dev/test gap. Runs Claude itself as the coordinator with subagent executors in isolated git worktrees; for the standalone `arbor` CLI tool see references/arbor-upstream.md.

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This skill confirms whether a hospital has the necessary policies and expertise to support inpatient insulin pump therapy, including informed consent, standardized order sets, and device management guidance for imaging and surgical procedures. Triggered by questions such as "Are hospital policies and expertise in place for insulin pump use?" to ensure safe continuation of pump therapy in noncritical illness.

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Suggests initiating inpatient CGM for select diabetic patients at high risk for hypoglycemia based on Table 3 criteria. Triggers include "Should I initiate CGM for this hospitalized diabetic patient at high risk for hypoglycemia?" or "Is inpatient CGM warranted for this patient?"

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If CGM is not available, continue monitoring blood glucose with point-of-care testing as an alternative option. Trigger phrases include: "CGM is not available, what should we use for glucose monitoring?

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Apply the four published expert-consensus clinical scenarios to manage GI adverse events in complex GLP-1 receptor agonist patients — persistent nausea mid-titration, GERD/heartburn after up-titration, elderly with sarcopenia risk, and insulin-treated elderly with CKD plus diarrhoea. Use when a clinician describes a patient resembling one of these archetypes, or asks "how to manage GLP-1 in an elderly patient with CKD", "patient on liraglutide developed reflux", "sarcopenia worry on semaglutide in 80-year-old", or "persistent nausea on semaglutide despite escalation". Grounded in Gorgojo-Martínez 2023 Table 4.

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Provides a monitoring schedule for patients receiving GnRH agonist therapy for pubertal suppression. Trigger phrases include 'patient undergoing GnRH agonist therapy' or 'initiating pubertal suppression'.

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This skill recommends against initiating puberty blocking or gender-affirming hormone treatment in prepubertal children diagnosed with gender dysphoria or gender incongruence. Clinical triggers include a young child presenting with GD/gender incongruence and caregivers or clinicians considering hormone intervention.

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Assesses whether hysterectomy and oophorectomy are medically necessary as part of gender-affirming surgery for transgender patients. Triggered when a patient is planning gender-affirming surgery and clinicians need to determine if total hysterectomy and oophorectomy should be included.

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Assesses Tanner stage to determine if physical changes of puberty have begun (stage G2/B2 or higher) for considering pubertal suppression. Triggered when a clinician evaluates pubertal development in an adolescent patient.

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Applies standard breast-screening guidelines for transgender females who have been assessed as having no known increased risk of breast cancer. Trigger phrases include transgender female and assessed as no increased breast cancer risk.

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This skill determines whether testicular volume should be used as the primary or sole indicator of sexual development in male childhood cancer survivors who have received gonadotoxic treatments such as alkylating agents or testicular radiotherapy. Triggers include clinician questions like “Can I use testicular volume to assess puberty in this male survivor after chemotherapy?” or “Is testis size reliable for sexual maturity evaluation post‑radiation?”

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Determines if a patient has completed ≥1 year of consistent and compliant hormone therapy for genital surgery approval. Triggers include patient requesting genital surgery and being on hormone therapy.

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Determines whether a patient meets the minimum age requirement (≥18 years or legal age of majority) for genital surgery that includes gonadectomy and/or hysterectomy. Trigger phrase: patient requests gonadectomy or hysterectomy as part of gender-affirming genital surgery.

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Assists clinicians in determining whether to proceed with social transition for prepubertal youth experiencing gender dysphoria or gender incongruence. Triggers include prepubertal youth with GD/gender incongruence and discussions about initiating social transition.

日本語の概要は準備中です。原文の説明を表示しています。

Determines if patient meets ICD-10 criteria for transsexualism. Triggered when a clinician uses ICD-10 for diagnostic purposes in gender identity assessment.

日本語の概要は準備中です。原文の説明を表示しています。

This skill determines whether an adolescent or adult patient meets DSM-5 criteria for gender dysphoria (gender incongruence) by evaluating the presence of at least two of six specified criteria over a minimum 6-month duration, accompanied by clinically significant distress or impairment. It is triggered when a clinician queries whether the patient's reported symptoms align with gender dysphoria, such as persistent incongruence between experienced/expressed gender and designated gender.

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This skill indicates the need for periodic prolactin monitoring in transgender females undergoing estrogen therapy. Clinical triggers include a transgender female patient receiving estrogen treatment.

日本語の概要は準備中です。原文の説明を表示しています。

This skill checks for contraindications or sources of inaccuracy that may affect continuous glucose monitoring (CGM) reliability in hospitalized adults. It is triggered when clinicians ask, “Are there factors that could make CGM unreliable?” or when assessing for skin infection, hypoperfusion, hypovolemia, vasoactive/pressor therapy, or medications such as acetaminophen >4 g/day, dopamine, vitamin C, or hydroxyurea.

日本語の概要は準備中です。原文の説明を表示しています。

Suggests real-time CGM over no CGM for outpatients with type 2 diabetes who use insulin and/or sulfonylureas and are at high risk for hypoglycemia to detect and prevent low glucose events. Consider when initiating CGM in T2D patients on insulin/SU with a history of severe hypoglycemia or impaired awareness of hypoglycemia (IAH).

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This skill suggests continuing personal CGM with or without ADIP rather than discontinuation for inpatients already using it who are at high risk for hypoglycemia. Trigger phrases include "Should I continue or discontinue personal CGM for this inpatient who is already using it?" and "Is it appropriate to maintain personal CGM during hospitalization?"

日本語の概要は準備中です。原文の説明を表示しています。

Verify that insulin pump supplies (provided by patient or family) will be available throughout the hospitalization to support continued pump use. Triggered by questions such as "Do we have sufficient pump supplies for the hospital stay?"

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Suggests short-term, intermittent real-time CGM use in adult patients with type 2 diabetes not on prandial insulin who have A1C ≥7% and are willing and able to use the device. Triggered by phrases such as “T2DM basal-only, A1C ≥7%, consider intermittent CGM” or “Short-term CGM for non-prandial T2DM with elevated A1C”.

日本語の概要は準備中です。原文の説明を表示しています。

Recommends RT-CGM devices for adult patients with well-controlled type 1 diabetes who are willing and able to use the devices on a nearly daily basis. Trigger phrases include 'Controlled T1DM patient interested in CGM' and 'Consider RT-CGM for glycemic stability in well-controlled T1DM'.

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If CGM fails or is removed, revert the insulin pump to manual mode provided basic criteria for pump use in hospital are still met. Trigger phrase: "CGM failed, should we switch pump to manual mode?

日本語の概要は準備中です。原文の説明を表示しています。