Online palliative care education and mentorship in Nepal: Project ECHO - a novel approach to improving knowledge and self-efficacy among interprofessional health-care providers.

BACKGROUND: Palliative care access in Nepal is severely limited, with few health-care providers having training and skills to pain management and other key aspects of palliative care. Online education suggests an innovation to increase access to training and mentoring, which addresses common learning barriers in low- and middle-income countries. Project ECHO (Extensions for Community Health Care Outcomes) is a model of online education which supports communities of practices (COPs) and mentoring through online teaching and case discussions. The use of online education and Project ECHO in Nepal has not been described or evaluated. SETTING: An online course, consisting of 14 synchronous weekly palliative care training sessions was designed and delivered, using the Project ECHO format. Course participants included health-care professionals from a variety of disciplines and practice settings in Nepal. OBJECTIVES: The goal of this study was to evaluate the impact of a virtual palliative care training program in Nepal on knowledge and attitudes of participants. METHODS: Pre- and post-course surveys assessed participants' knowledge, comfort, and attitudes toward palliative care and evaluated program acceptability and barriers to learning. RESULTS: Forty-two clinicians, including nurses (52%) and physicians (48%), participated in program surveys. Participants reported significant improvements in their knowledge and attitudes toward core palliative care domains. Most participants identified the program as a supportive COP, where they were able to share and learn from faculty and other participants. CONCLUSION: Project ECHO is a model of online education which can successfully be implemented in Nepal, enhancing local palliative care capacity. Bringing together palliative care local and international clinical experts and teachers supports learning for participants through COP. Encouraging active participation from participants and ensuring that teaching addresses availability and practicality of treatments in the local health-care context addresses key barriers of online education. SIGNIFICANCE OF RESULTS: This study describes a model of structured virtual learning program, which can be implemented in settings with limited access to palliative care to increase knowledge and attitudes toward palliative care. The program equips health-care providers to better address serious health-related suffering, improving the quality of life for patients and their caregivers. The program demonstrates a model of training which can be replicated to support health-care providers in rural and remote settings.

Symptoms 6 months following SARS-CoV-2 infection in Nepali women.

In Nepal, over 1 million individuals have tested positive for SARS-CoV-2. We sought to describe the frequency of nonrecovery from this infection at 6 months and associated symptoms. We conducted a retrospective cohort study of 6142 women who had positive and negative PCR tests for this infection 6 months previously at 3 institutions in Kathmandu. In telephone interviews women provided information on 22 symptoms and their intensities, health status and history, and functional status. Of 3732 women who had tested PCR positive, 630 (16.9%) reported that they were unrecovered. These 630 unrecovered women were distinguished statistically from the 3102 recovered women by more frequent histories of allergies, rheumatoid disease, BCG immunization, Covid vaccination, strep throat and recent URIs, and both weight gain and weight losses of more than 5 kg in the 6 months following testing, and stressful events in the preceding year. Fatigue, pain, difficulty remembering, shortness of breath, heat and cold intolerance and unrefreshing sleep were reported in 41.9% to 10.5% of these 630 unrecovered women. Six months after confirmed SARS-CoV-2 infection 16.9% of Nepali women have long-COVID manifested as an immune, metabolic, and hormonal systems disruptive and dysfunction syndrome.

Striving toward safe abortion services in Nepal: A review of barriers and facilitators.

Background and Aims: Despite the decriminalization of abortion in Nepal in 2002, unsafe abortion is still a significant contributor to maternal morbidity and mortality. Nepal has witnessed a significant drop in abortion-related severe complications and maternal deaths owing to the legalization of abortion laws, lowered financial costs, and wider accessibility of safe abortion services (SAS). However, various factors such as sociocultural beliefs, financial constraints, geographical difficulties, and stigma act as barriers to the liberal accessibility of SAS. This review aimed to determine key barriers obstructing women's access to lawful, safe abortion care and identify facilitators that have improved access to and quality of abortion services. Methods: A systematic search strategy utilizing the databases PubMed, CINAHL, Scopus, and Embase was used to include studies on the accessibility and safety of abortion services in Nepal. Data were extracted from included studies through close reading. Barriers and facilitators were then categorized into various themes and analyzed. Results: Of 223 studies, 112 were duplicates, 73 did not meet the inclusion criteria, and 18 did not align with the research question; thus, 20 studies were included in the review. Various barriers to SAS in Nepal were categorized as economic, geographic, societal, legal/policy, socio-cultural, health systems, and other factors. Facilitators improving access were categorized as economic/geographic/societal, legal/policy, socio-cultural, and health systems factors. The patterns and trends of barriers and facilitators were analyzed, grouping them under legal/policy, socio-cultural, geographic/accessibility, and health systems factors. Conclusion: The review identifies financial constraints, unfavorable geography, lack of infrastructure, and social stigmatization as major barriers to SAS. Economics and geography, legalization, improved access, reduced cost and active involvement of auxiliary nurse-midwives and community health volunteers are key facilitators.

A Consecutive Series Study of the Frequencies, Intensities, and Natural History of Symptoms Following COVID-19 Infection in Nepali Men.

BACKGROUND: In Nepal, approximately one million individuals, two-thirds men, have tested positive for COVID-19. The recovery picture from this infection is undescribed. METHODS: At one major testing institution in Kathmandu, we attempted to contact men three-four months following documentation of a positive PCR Covid test. If the men contacted consented and reported that they had not completely recovered from their Covid infection, we then sought their answers about the presence and intensities of 23 symptoms. RESULTS: Of 2043 consecutive test-positive men, we successfully contacted 1254 men/or family members. 14 men had died before our calls, and two reported having cancer or tuberculosis, providing 1238 individuals. 318 (25.7%) reported that they were unrecovered and 311 of these men were successfully interviewed. At a median of 3.5 months from diagnosis, 216 (17.4%) men reported fatigue, 153 (12.4%) pain, 134 (10.8%) difficulty remembering, 133 (10.7%) reduced physical activity, 114 (9.2%) shortness of breath, and 114 (9.2%) poor sleep. By 6 and 9 months, 108 (8.7%) and 55 (4.4%) of men respectively were still unrecovered. CONCLUSIONS: In this PCR Covid test-positive series of symptomatic men, recovery was significantly prolonged compared with other viral illnesses.

Technical note: Progressive deep learning: An accelerated training strategy for medical image segmentation.

BACKGROUND: Recent advancements in Deep Learning (DL) methodologies have led to state-of-the-art performance in a wide range of applications especially in object recognition, classification, and segmentation of medical images. However, training modern DL models requires a large amount of computation and long training times due to the complex nature of network structures and the large number of training datasets involved. Moreover, it is an intensive, repetitive manual process to select the optimized configuration of hyperparameters for a given DL network. PURPOSE: In this study, we present a novel approach to accelerate the training time of DL models via the progressive feeding of training datasets based on similarity measures for medical image segmentation. We term this approach Progressive Deep Learning (PDL). METHODS: The two-stage PDL approach was tested on the auto-segmentation task for two imaging modalities: CT and MRI. The training datasets were ranked according to similarity measures between each sample based on Mean Square Error (MSE), Peak Signal-to-Noise Ratio (PSNR), Structural Similarity Index (SSIM), and the Universal Quality Image Index (UQI) values. At the start of the training process, a relatively coarse sampling of training datasets with higher ranks was used to optimize the hyperparameters of the DL network. Following this, the samples with higher ranks were used in step 1 to yield accelerated loss minimization in early training epochs and the total dataset was added in step 2 for the remainder of training. RESULTS: Our results demonstrate that the PDL approach can reduce the training time by nearly half (∼49%) and can predict segmentations (CT U-net/DenseNet dice coefficient: 0.9506/0.9508, MR U-net/DenseNet dice coefficient: 0.9508/0.9510) without major statistical difference (Wilcoxon signed-rank test) compared to the conventional DL approach. The total training times with a fixed cutoff at 0.95 DSC for the CT dataset using DenseNet and U-Net architectures, respectively, were 17 h, 20 min and 4 h, 45 min in the conventional case compared to 8 h, 45 min and 2 h, 20 min with PDL. For the MRI dataset, the total training times using the same architectures were 2 h, 54 min and 52 min in the conventional case and 1 h, 14 min and 25 min with PDL. CONCLUSION: The proposed PDL training approach offers the ability to substantially reduce the training time for medical image segmentation while maintaining the performance achieved in the conventional case.

Building a 'Virtual Library': continuing a global collaboration to strengthen research capacity within Nepal and other low- and middle-income countries.

To fill the gap in health research capacity-building efforts, we created the 'Virtual Library' (VL) - a web-based repository of context-relevant resources for health researchers in low- and middle-income countries (LMICs). This paper describes the participatory process used to systematically develop the VL, and describes how our interprofessional team - representing both an LMIC (Nepal) and a high-income country (HIC) (USA, US) - engaged in shared meaning-making. A team of researchers and clinicians representing a range of subdisciplines from Nepal and the US created a replicable search strategy and standardized Resource Screening Guide (RSG) to systematically assess resources to be included within the VL. Descriptive methods were used to summarize findings from the RSG and lessons learned from the collaborative process. Collectively, 14 team members reviewed 564 potential resources (mean = 40, SD = 22.7). Mean RSG score was 7.02/10 (SD = 2). More than 76% of resources met each of the four quality criteria (relevant; reputable, accessible; understandable). Within the published VL, 298 resources were included, organized by 15 topics and 45 sub-topics. Of these, 223 resources were evaluated by the RSG; 75 were identified by team member expertise. The collaborative process involved regular meetings, iterative document revisions, and peer review. Resource quality was better than expected, perhaps because best practices/principles related to health research are universally relevant, regardless of context. While the RSG was essential to systematize our search and ensure reproducibility, team member expertise was valuable. Pairing team members during peer-review led to bi-directional knowledge sharing and was particularly successful. This work reflects a highly collaborative global partnership and offers a model for future health research capacity-building efforts. We invite engagement with the Virtual Library as one supportive pillar of infrastructure to develop individual and institutional research capacity.

Investigation of beam delivery time for synchrotron-based proton pencil beam scanning system with novel scanning mode.

Objective.To investigate synchrotron-based proton pencil beam scanning (PBS) beam delivery time (BDT) using novel continuous scanning mode.Approach.A BDT calculation model was developed for the Hitachi particle therapy system. The model was validated against the measured BDT of 36 representative clinical proton PBS plans with discrete spot scanning (DSS) in the current Hitachi proton therapy system. BDTs were calculated with the next generation using Mayo Clinic Florida system operating parameters for conventional DSS, and novel dose driven continuous scanning (DDCS). BDTs of DDCS with and without Break Spots were investigated.Main results.For DDCS without Break Spots, the use of Stop Ratio to control the transit dose largely reduced the beam intensity and consequently, severely prolonged the BDT. DDCS with Break Spots was able to maintain a sufficiently high beam intensity while controlling transit dose. In DDCS with Break Spots, tradeoffs were made between beam intensity and number of Break Spots. Therefore, BDT decreased with increased beam intensity but reached a plateau for beam intensity larger than 10 MU s-1. Averaging over all clinical plans, BDT was reduced by 10% for DDCS with Break Spots compared to DSS.Significance.DDCS with Break Spots reduced BDT. DDCS has the potential to further reduce BDT under the ideal scenario which requests both stable beam intensity extraction and accurately modelling the transit dose. Further investigation is warranted.

Cancer Prevention Strategies for Nepal.

In Nepal, the commonest major malignancies and causes of cancer death are lung, cervix, stomach, breast, head and neck (lip, mouth, pharynx, larynx), gallbladder, ovary and liver. There are seven cancer-causative exposures which should be the focus of attention such as; tobacco smoking in 29% of men, and 6% of women, solid fuel burning in 69% of homes (multiple cancers), betel-nut chewing in 40 % of men and 3% of women (head and neck cancers), alcohol abuse (liver and other cancers), Human Papilloma Virus (cervical cancer), Helicobacter pylori (stomach cancer) and Hepatitis B virus (liver cancer). To better address these reducible exposures, we suggest greater targeted strategies in three areas: Public health messaging for tobacco, solid-fuel burning, betel-nut, and alcohol; national policies for Hepatitis B virus vaccination; and analytic epidemiological and interventional research for Human Papilloma Virus and helicobacter.

Abnormal Uterine Bleeding among Women Visiting Gynecology Out- patient Department of a Tertiary Care Hospital: A Descriptive Cross- sectional Study.

INTRODUCTION: Abnormal uterine bleeding accounts for more than 70% of complaints in peri- and post-menopausal women. The main purpose of investigating them is to rule out premalignant and malignant endometrial lesions. This study aimed to find out the prevalence of abnormal uterine bleeding among out-patients visiting the gynecology department of a tertiary care hospital. METHODS: This descriptive cross-sectional study was conducted in the Department of Obstetrics and Gynecology of a tertiary care center from August 1, 2020 to April 23, 2021. Ethical approval was obtained from the Institutional Review Committee of the same institution (IRC-LMC 07-C/020). A total of 2680 women visiting gynecology outpatient departments were included by convenience sampling technique. Women with abnormal uterine bleeding were evaluated by endometrial thickness measurement and endometrial biopsies. Statistical Package for the Social Sciences version 16 was used for data analysis. Point estimate at 95% Confidence Interval was calculated along with frequency, percentage, mean and standard deviation. RESULTS: Among 2680 women visiting the gynecology outpatient department, the prevalence of abnormal uterine bleeding was 240 (8.9%) (7.82-9.98 at 95% Confidence Interval). The mean endometrial thickness was 10.15±6.63mm. Majority of patients 104 (43.3%) had endometrial thickness >10mm. Sixty-six (27.8%) patients had disordered proliferative endometrium while endometrial carcinoma was noted in three (1.2%) patients. Atrophic endometrium was observed in 17 (7.2%) and endometrial hyperplasia in nine (3.8%) patients. CONCLUSIONS: The prevalence of abnormal uterine bleeding was found to be higher in comparison to other studies. Disordered proliferative endometrium was the most common histopathological finding followed by secretory phase endometrium.

Tied with Hair Strands- A Case of Hair Tourniquet Syndrome involving Labia Minora in an Adult Woman from Nepal.

Hair tourniquet syndrome is the strangulation of body appendages by a thread of hair. If neglected, it results in lymphatic obliteration, venous congestion, and arterial obstruction. A 25 years lady with a history of insect bite presented with intense itching and painful swelling in the left labia minora for three days. She had tied the swollen part with a bunch of hair strands leading to painful swelling. Local inspection revealed a 2x2 cm swelling in the left labia minora. The tourniquet effect was released by cutting the hair. Hair tourniquet syndrome involving female genitalia requires immediate recognition and treatment. Keywords: Hair tourniquet syndrome; hair-thread tourniquet syndrome; labia minora.

Long COVID Patient Symptoms and its Evaluation and Management.

While the acute case burdens and deaths from the COVID-19 pandemic (in Nepal approaching 700,000 and 10,000 respectively) have been costly, the characteristics and potentially huge dimensions of the chronic disease sequelae of this infectious disease are only slowly becoming apparent. We reviewed Pub Med, major medical meeting and medical journal, and investigative journalist materials seeking to frame and describe COVID-19 chronic disease. The consequences of COVID-19 infections follow major organ damage, and induction of immunological and hormonal systems dysfunction. The first injuries are consequent to direct viral effects on tissues, and vasculitis, endothelialitis, thrombosis and inflammatory events. Pulmonary, cardiac, brain, and kidney tissues incur function-limiting damage, with dyspnea, arrythmias, decreased exercise capacity, cognitive dysfunction, and decreased glomerular filtration rates. The second process is characterized by immune dysregulation and autoimmunity, and dysfunction of hormonal regulation systems, with high, fluctuating levels of physical and mental fatigue, multiple-site pain and ache, and non-restorative sleep, in 10-30% of cases. This communication proposes evaluation and management of chronic COVID-19 patients with efficient assessment of commonest symptoms, targeted physical examination and organ function testing, and interventions based on specific organ functional status, and experience with similar chronic immune syndromes, such as myalgic encephalomyelitis.

Illness Representations of Hypertension among Nepali Patients at a Tertiary Care Hospital Clinic: An exploratory survey.

BACKGROUND: The prevalence of stage 2 hypertension approaches one-third in adult Nepalis and despite inexpensive effective treatment, long-term compliance is poor. World-wide, a major impediment is the incongruity between hypertension and patients' symptom-based illness representations. The Common-Sense Model of Self-regulation was used to investigate Nepali illness representations through open-ended interviews of patients with hypertension. METHODS: In a tertiary hospital setting, 50 self-identified hypertensive patients were interviewed about their representations of health, hypertension, and hypertensive treatment. Responses were analyzed with a modified Interpretative Phenomenological Analysis. RESULTS: An Ayurvedic-influenced health model appeared in illness identity and coping responses. Hypertension was identified as a serious disease having observable, wide-ranging symptoms with chronic and intermittent timelines. Concerns included side-effects and barriers to treatment. CONCLUSIONS: Further confirmation and investigation of Nepali common-sense hypertension models in a sample size sufficient for factor analysis is warranted for effective adherence interventions.

Futile Sexual Homicide in Nepal: A Case Report.

Although cases of sexual offenses are not uncommon in children, they present to the Emergency Department seeking treatment for a medical cause. Sometimes the history of abuse is missed by the treating clinicians who are only focused upon the presenting complaint and not upon the underlying cause. Furthermore, the lack of reporting of sexual abuse in medical literatures makes them a rarity in the Nepalese scenario. We present an uncommon case of a child where the perpetrator who tried to silence her during the sexual intercourse made a futile attempt to kill her cutting her throat with a sickle.

Reorganizing Hospital Cancer Care In Nepal.

While mortality rates for major common cancers- of the lung, breast, stomach, ovary, and lymphomas-- have declined significantly in high-income countries over the last decade, comparable rates for these malignancies have not fallen in Nepal. The explanations for the high-income country mortality trends are multiple and certainly include incidence reductions, but better treatments are also contributory. How to bring to Nepal the global lessons in achieving better cancer care is uncertain. We need to create an environment of ideas and a powerful vision to meet the needs for better major cancer management for Nepalis. Broadly, the Nepalese challenges are in creating more accessible and affordable care of sufficiently high-quality to make a difference. Hospitals are the major places where these issues have to be considered. To address these challenges, we offer a vision and suggest here strategies of major organizational changes in: Innovative staffing models, emphasizing teamwork, with increases in responsibilities, activities and work force percentages of non-physician health professionals; Increased outpatient care and tele-health; 3.Creating and following evidence-based diagnostic pathway and treatment clinical practice guidelines and checklists; 4. Increased application of information technology tools, particularly electronic medical records; and 5. Service implementation research evaluating quality based on structure, process and outcomes of care. Developing such effective changes requires strong community linkages, local institutional-specific coalition initiatives and experimentation, and national and international collaborations and financial support to effect practical and data-based plans and budgets. Keywords: Guidelines; improving treatment; information technology tools; outpatient services; staffing models; tele-health.

Assessment of Client Satisfaction in Labour and Delivery Services in a Tertiary Hospital in Western Nepal.

BACKGROUND: Patient satisfaction is an individual's positive evaluation of a distinct dimension of health care. This study aimed to assess client satisfaction with maternity care in a tertiary hospital in the western region of Nepal. METHODS: This cross-sectional study was conducted among 405 delivered women. A structured questionnaire of 21 items was used as a tool during exit interviews at their discharge. Each item was assessed on 5 points Likert scale. Student's t-test and one-way ANOVA tests were applied to analyse parametric data. Binary logistic regression analysis was applied to identify the association of predictors with the satisfaction level. Strength of association was interpreted using odds ratio and 95% confidence interval. RESULTS: The mean waiting time was 16.94 +5.57 minutes. Education level of the clients was statistically significant with the mean satisfaction score (p<0.001). Women with unwanted pregnancies were more satisfied than those with wanted pregnancies (p<0.001). Lower complete satisfaction rates were observed for pain control (6.4%), information at discharge (14.6%) and the degree of privacy in the ward (13.6%). Mothers who underwent instrumental delivery were less satisfied with health worker's attitudes than those having vaginal deliveries (odds ratio 0.20, 95% confidence interval:0.05-0.84). Those having uncomplicated deliveries were 3.5 times more likely to be satisfied (odds ratio 3.50, 95% confidence interval: 1.1-11.5) with health workers communication. Mothers with waiting time less than 15 minutes were more satisfied. CONCLUSIONS: Lower educational level, unwanted pregnancy and shorter waiting time were associated with higher maternal satisfaction.

The Tragic Plight of Frontline COVID-19 Warriors in Nepal.

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Effect of Titanium Miniplate Fixation on Hinge Fracture and Hinge Fracture Displacement Following Cervical Open-Door Laminoplasty.

BACKGROUND: Cervical spondylotic myelopathy is a neuromotor disorder responsible for functional limitations and decreased daily activities. Expansive open-door laminoplasty is the widely accepted procedure for the treatment of multilevel cervical spondylotic myelopathy. Among the various fixation procedures to secure the open lamina, miniplate fixation provides better clinical and radiological outcomes. However, the immediate effects on hinge fracture and hinge fracture displacement following miniplate fixation have not been proven until now. The purpose of our study was to elucidate the impact of cervical open-door angle on the status of spinal cord expansion and hinge fracture, hinge fracture displacement, and the role of implants used during surgery. METHODS: For this retrospective study, 122 patients who had undergone surgery from September 2016 to November 2017 with preoperative and postoperative radiographs were enrolled. Clinical and radiological outcomes were assessed before and after surgery. RESULTS: There were no significant differences in demographics, surgery time, blood loss, medical comorbidities, or perioperative and postoperative complications between 2 groups. The recovery rate and Nurick score before and at the follow-up show no statistical significance between the 2 groups, P value > .05 (P = .672) and P > .05 (P = .553), respectively. The statistical analysis shows that the mean hinge fracture in the miniplate group with a cervical open angle >30° was 2.42 ± 1.68 and with a <30° open angle, 0.05 ± 0.23; whereas, in the anchor group the mean hinge fracture in >30° cervical open angle was 2.227 ± 2.50 and in <30° was 0.409 ± 0.503. The results revealed statistical significance between 2 implant groups, P = .024 in the aspect of hinge fracture displacement and implant used. CONCLUSION: Laminoplasty by titanium miniplate fixation holds the laminae securely, prevents hinge fracture displacement, and promotes spinal cord expansion better than suture anchor fixation.

When sexual offence is an unexpected diagnosis - exploration of medical, legal and social aspects in Nepalese scenario.

In Nepal, following allegations of sexual assault, the survivor is taken by the police to a Government Hospital for medical examination and sample collection. To provide an integrated service to survivors of gender-based violence, a One-Stop Crisis Management Centre (OCMC) is established in many Government Hospitals. However, paediatric survivors of sexual abuse frequently seek initial care at the emergency department, as most present with a medical complaint rather than for sexual abuse. It is therefore important to train emergency physicians with the skills required to identify the features and diagnose a case of sexual assault. We present a case where the diagnosis of sexual assault of a child was an incidental finding and discuss the challenges faced in dealing with such cases in non-OCMC Hospital.

Reproductive Health Issues and Depression in Wives of Labor Migrant Workers.

BACKGROUND: Young Nepalese men have been forced to migrate to other countries in search of better opportunities. Wives of these migrant workers are in a vulnerable state and face various problems. The aim of this study wasto assess the prevalence of reproductive health problems and depression in this sub-population and to compare it with women living together with their husbands. METHODS: This is a hospital based case control study where depression and reproductive health problems including gender based violence were compared between wives of migrant workers and women living with their husbands. Structured questionnaire was used to assess reproductive symptomatology and Becks depression Inventory-II was used to measure level of depression. RESULTS: During the study period, 38.65% (2193) of all women were wives of migrant workers. India was the country where most 34.6% (73) men migrated. Mean duration of migration was 51.96 months (SD= 63.27). Moderate to severe depression was present in 42.6% (90) of wives of migrant workers and 80.09% of these women experienced some form of gender based violence. Reproductive tract symptoms and gender based violence and depression were significantly more present in these women (p<0.000). CONCLUSIONS: Depression and reproductive health problems weremore prevalent in wives of labor migrant workers than in women living with their husbands. The physical and mental health needs of this sub-population warrants screening strategies and preventive measures.

Dosimetric evaluation of 4D-CBCT reconstructed by Simultaneous Motion Estimation and Image Reconstruction (SMEIR) for carbon ion therapy of lung cancer.

PURPOSE: Motion management is critical for the efficacy of carbon ion therapy for moving targets such as lung tumors. We evaluated the feasibility of using four-dimensional cone beam computed tomography (4D-CBCT) reconstructed by Simultaneous Motion Estimation and Image Reconstruction (SMEIR) for dose calculation and accumulation in carbon ion treatment of lung cancer. METHODS: Motion-compensated 4D-CBCT images were reconstructed with the SMEIR algorithm to capture the most updated anatomy and motion with an updated interphase motion model on the treatment day. Projections of all CBCT phases were simulated from the planning 4D-CT by the ray tracing technique. Treatment planning and dose calculation were performed with a GPU-based Monte Carlo dose calculation software for carbon ion therapy. The treatment plan was optimized on the average computed tomography (CT) to obtain optimal intensity of the carbon ions. From the optimized plan, dose distributions on individual phases of 4D-CT and 4D-CBCT were calculated by the Monte Carlo-based dose engine. Dose accumulation was performed on 4D-CBCT images using deformable vector fields (DVF) generated by SMEIR. The accumulated planning target volume (PTV) dose based on 4D-CBCT was then compared to the accumulated dose calculated on 4D-CT, where the DVFs between different phases were obtained by the demons deformable registration algorithm. RESULTS: Dose value histograms (DVH) as well as absolute deviations of the maximum dose ( Δ D max ), mean dose ( Δ D mean ), and dose coverage metrics ( Δ V 95 % and Δ V 100 % ) for PTV were quantitatively evaluated for the two sets of plans. Good agreement was found between the 4D-CT and 4D-CBCT-based PTV-DVH curves. The average values of Δ D max , Δ D mean , Δ V 95 % , and Δ V 100 % calculated between the 4D-CT and SMEIR-4D-CBCT-based plans were 1.91 % , 3.55 % , 2.12%, and 1.15 % , respectively, for the PTVs of ten patient case studies. CONCLUSIONS: Based on these results, SMEIR-reconstructed 4D-CBCTs can potentially be used for motion estimation, dose evaluation, and adaptive treatment planning in lung cancer carbon ion therapy.