infective endocarditis vegetations clinical images free use medical education

mkdir -p /home/daytona/workspace/ie-ppt && ls /home/daytona/workspace/ie-ppt/

~/ie-ppt/build_ie_ppt.js

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// Fetch images
const imageUrls = [
  "https://upload.medbullets.com/topic/120026/images/infective_endocarditis_hand.jpg",
  "https://upload.medbullets.com/topic/120026/images/vegetation%20of%20valve.jpg",
  "https://upload.medbullets.com/topic/120026/images/skin_oslers_nodes2.jpg",
  "https://upload.medbullets.com/topic/120026/images/roth spots.jpg",
  "https://upload.medbullets.com/topic/120026/images/splinter hemorrhages.jpg",
  "https://upload.medbullets.com/topic/120026/images/janeway_lesion.jpg",
  "https://upload.medbullets.com/topic/120026/images/endocarditis_ultrasound.jpg"
];

let images = [];
try {
  const fetchResult = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { timeout: 30000 }
  ).toString();
  images = JSON.parse(fetchResult);
} catch (e) {
  console.error("Image fetch error:", e.message);
  images = imageUrls.map(u => ({ url: u, base64: null, error: e.message }));
}

console.log("Images fetched:", images.map(i => ({ url: i.url.substring(0,60), hasData: !!i.base64, error: i.error })));

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Infective Endocarditis";
pres.author = "Medical Education";

// Color palette
const DARK_BG = "0D2137";     // deep navy
const ACCENT = "C0392B";      // crimson red
const ACCENT2 = "E74C3C";     // lighter red
const LIGHT_BG = "EBF5FB";    // very light blue
const WHITE = "FFFFFF";
const DARK_TEXT = "1A2530";
const SUBTEXT = "2C3E50";
const YELLOW_ACC = "F39C12";   // for highlights
const TEAL = "117A8B";         // supporting teal

function addTitleSlide(pres) {
  const slide = pres.addSlide();
  // Dark background
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG } });
  // Red accent bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 4.2, w: 10, h: 0.12, fill: { color: ACCENT } });
  // Decorative top bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.08, fill: { color: ACCENT } });
  // Heart icon area (circle)
  slide.addShape(pres.ShapeType.ellipse, { x: 4.2, y: 0.5, w: 1.6, h: 1.6, fill: { color: ACCENT }, line: { color: ACCENT2, width: 2 } });
  slide.addText("♥", { x: 4.2, y: 0.6, w: 1.6, h: 1.2, fontSize: 36, color: WHITE, align: "center", bold: true });

  slide.addText("INFECTIVE ENDOCARDITIS", {
    x: 0.5, y: 2.3, w: 9, h: 0.9,
    fontSize: 38, bold: true, color: WHITE, align: "center",
    charSpacing: 3, fontFace: "Calibri"
  });
  slide.addShape(pres.ShapeType.rect, { x: 2.5, y: 3.25, w: 5, h: 0.04, fill: { color: ACCENT } });
  slide.addText("A Comprehensive Overview", {
    x: 0.5, y: 3.4, w: 9, h: 0.5,
    fontSize: 18, italic: true, color: "A8D8EA", align: "center", fontFace: "Calibri"
  });
  slide.addText("Reference: Ghai Essential Pediatrics | Robbins Pathology | Braunwald's Heart Disease", {
    x: 0.5, y: 4.35, w: 9, h: 0.4,
    fontSize: 10, color: "A0B4C0", align: "center", fontFace: "Calibri"
  });
}

function addSectionHeader(pres, title, subtitle) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG, transparency: 20 } });
  slide.addShape(pres.ShapeType.rect, { x: 0.5, y: 1.8, w: 9, h: 0.06, fill: { color: WHITE } });
  slide.addText(title, {
    x: 0.5, y: 1.2, w: 9, h: 0.8,
    fontSize: 36, bold: true, color: WHITE, align: "center", fontFace: "Calibri"
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 1, y: 2.05, w: 8, h: 0.5,
      fontSize: 16, color: "F5CBA7", align: "center", italic: true, fontFace: "Calibri"
    });
  }
}

function addContentSlide(pres, title, bullets) {
  const slide = pres.addSlide();
  // Light background
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F5F9FC" } });
  // Left accent bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
  // Title bar
  slide.addShape(pres.ShapeType.rect, { x: 0.18, y: 0, w: 9.82, h: 0.95, fill: { color: DARK_BG } });
  slide.addText(title, {
    x: 0.35, y: 0.08, w: 9.4, h: 0.75,
    fontSize: 22, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri"
  });

  const bulletItems = bullets.map((b, i) => {
    if (typeof b === "string") {
      return { text: b, options: { bullet: { code: "2022" }, breakLine: i < bullets.length - 1, fontSize: 15.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } };
    }
    return b;
  });
  slide.addText(bulletItems, {
    x: 0.45, y: 1.05, w: 9.3, h: 4.45,
    valign: "top", fontFace: "Calibri"
  });
  return slide;
}

function addTwoColumnSlide(pres, title, leftTitle, leftBullets, rightTitle, rightBullets) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F5F9FC" } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: TEAL } });
  slide.addShape(pres.ShapeType.rect, { x: 0.18, y: 0, w: 9.82, h: 0.95, fill: { color: DARK_BG } });
  slide.addText(title, {
    x: 0.35, y: 0.08, w: 9.4, h: 0.75,
    fontSize: 22, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri"
  });

  // Left column header
  slide.addShape(pres.ShapeType.rect, { x: 0.35, y: 1.05, w: 4.5, h: 0.38, fill: { color: ACCENT }, rounding: false });
  slide.addText(leftTitle, { x: 0.35, y: 1.05, w: 4.5, h: 0.38, fontSize: 13, bold: true, color: WHITE, align: "center", valign: "middle", fontFace: "Calibri" });

  // Right column header
  slide.addShape(pres.ShapeType.rect, { x: 5.15, y: 1.05, w: 4.5, h: 0.38, fill: { color: TEAL }, rounding: false });
  slide.addText(rightTitle, { x: 5.15, y: 1.05, w: 4.5, h: 0.38, fontSize: 13, bold: true, color: WHITE, align: "center", valign: "middle", fontFace: "Calibri" });

  const leftItems = leftBullets.map((b, i) => ({ text: b, options: { bullet: { code: "25CF" }, breakLine: i < leftBullets.length - 1, fontSize: 14, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 3 } }));
  slide.addText(leftItems, { x: 0.35, y: 1.48, w: 4.5, h: 3.9, valign: "top" });

  const rightItems = rightBullets.map((b, i) => ({ text: b, options: { bullet: { code: "25CF" }, breakLine: i < rightBullets.length - 1, fontSize: 14, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 3 } }));
  slide.addText(rightItems, { x: 5.15, y: 1.48, w: 4.5, h: 3.9, valign: "top" });

  return slide;
}

function addImageSlide(pres, title, imgData, caption, bullets) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F5F9FC" } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT2 } });
  slide.addShape(pres.ShapeType.rect, { x: 0.18, y: 0, w: 9.82, h: 0.95, fill: { color: DARK_BG } });
  slide.addText(title, {
    x: 0.35, y: 0.08, w: 9.4, h: 0.75,
    fontSize: 22, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri"
  });

  if (imgData && imgData.base64) {
    slide.addImage({ data: imgData.base64, x: 0.35, y: 1.05, w: 4.2, h: 3.5 });
    slide.addShape(pres.ShapeType.rect, { x: 0.35, y: 4.55, w: 4.2, h: 0.35, fill: { color: DARK_BG } });
    slide.addText(caption, { x: 0.35, y: 4.55, w: 4.2, h: 0.35, fontSize: 9, color: WHITE, align: "center", italic: true, fontFace: "Calibri" });

    const bulletItems = bullets.map((b, i) => ({ text: b, options: { bullet: { code: "2022" }, breakLine: i < bullets.length - 1, fontSize: 14, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } }));
    slide.addText(bulletItems, { x: 4.8, y: 1.05, w: 4.95, h: 4.45, valign: "top" });
  } else {
    // fallback: all text
    const bulletItems = bullets.map((b, i) => ({ text: b, options: { bullet: { code: "2022" }, breakLine: i < bullets.length - 1, fontSize: 14.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } }));
    slide.addText(bulletItems, { x: 0.45, y: 1.05, w: 9.3, h: 4.45, valign: "top" });
    slide.addText(caption, { x: 0.45, y: 4.9, w: 9.3, h: 0.45, fontSize: 10, color: ACCENT, italic: true, fontFace: "Calibri" });
  }
  return slide;
}

function addTableSlide(pres, title, headers, rows) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F5F9FC" } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: YELLOW_ACC } });
  slide.addShape(pres.ShapeType.rect, { x: 0.18, y: 0, w: 9.82, h: 0.95, fill: { color: DARK_BG } });
  slide.addText(title, {
    x: 0.35, y: 0.08, w: 9.4, h: 0.75,
    fontSize: 22, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri"
  });

  const tableRows = [];
  // Header row
  const headerRow = headers.map(h => ({
    text: h,
    options: { bold: true, color: WHITE, fill: DARK_BG, fontSize: 13, align: "center", fontFace: "Calibri", valign: "middle" }
  }));
  tableRows.push(headerRow);

  rows.forEach((row, ri) => {
    const bgColor = ri % 2 === 0 ? "EBF5FB" : WHITE;
    tableRows.push(row.map((cell, ci) => ({
      text: cell,
      options: { color: DARK_TEXT, fill: bgColor, fontSize: 12, fontFace: "Calibri", valign: "middle", bold: ci === 0 }
    })));
  });

  slide.addTable(tableRows, {
    x: 0.35, y: 1.05, w: 9.3, h: 4.35,
    border: { type: "solid", color: "BDC3C7", pt: 0.5 },
    autoPage: false
  });
}

function addThankYouSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG } });
  // Decorative gradient circles
  slide.addShape(pres.ShapeType.ellipse, { x: -1, y: -1, w: 5, h: 5, fill: { color: ACCENT, transparency: 70 }, line: { color: "TRANSPARENT" } });
  slide.addShape(pres.ShapeType.ellipse, { x: 6, y: 2, w: 5, h: 5, fill: { color: TEAL, transparency: 70 }, line: { color: "TRANSPARENT" } });

  // Heart
  slide.addText("♥", {
    x: 4.2, y: 0.7, w: 1.6, h: 1.0,
    fontSize: 48, color: ACCENT2, align: "center", bold: true, fontFace: "Calibri"
  });

  slide.addText("THANK YOU", {
    x: 1, y: 1.8, w: 8, h: 1.1,
    fontSize: 52, bold: true, color: WHITE, align: "center", charSpacing: 8, fontFace: "Calibri"
  });

  slide.addShape(pres.ShapeType.rect, { x: 2.5, y: 3.0, w: 5, h: 0.06, fill: { color: ACCENT } });

  slide.addText("Infective Endocarditis", {
    x: 1, y: 3.2, w: 8, h: 0.5,
    fontSize: 20, italic: true, color: "A8D8EA", align: "center", fontFace: "Calibri"
  });

  slide.addText("Reference: Ghai Essential Pediatrics | Robbins & Kumar Basic Pathology\nBraunwald's Heart Disease | Harrison's Principles of Internal Medicine", {
    x: 1, y: 3.85, w: 8, h: 0.8,
    fontSize: 11, color: "7F8C8D", align: "center", fontFace: "Calibri"
  });
}

// ============================================================
// BUILD ALL 28 SLIDES
// ============================================================

// Slide 1: Title
addTitleSlide(pres);

// Slide 2: Table of Contents
const tocSlide = pres.addSlide();
tocSlide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F5F9FC" } });
tocSlide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT } });
tocSlide.addShape(pres.ShapeType.rect, { x: 0.18, y: 0, w: 9.82, h: 0.95, fill: { color: DARK_BG } });
tocSlide.addText("TABLE OF CONTENTS", { x: 0.35, y: 0.08, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri" });
const tocItems = [
  "1. Introduction & Definition", "2. Epidemiology", "3. Etiology & Risk Factors",
  "4. Pathogenesis", "5. Classification", "6. Clinical Features",
  "7. Peripheral Manifestations", "8. Duke Criteria", "9. Investigations",
  "10. Echocardiography", "11. Management", "12. Complications",
  "13. Surgery Indications", "14. Prevention & Prognosis"
];
const col1 = tocItems.slice(0, 7);
const col2 = tocItems.slice(7);
const col1Items = col1.map((b, i) => ({ text: b, options: { bullet: { code: "25B6" }, breakLine: i < col1.length - 1, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 5 } }));
const col2Items = col2.map((b, i) => ({ text: b, options: { bullet: { code: "25B6" }, breakLine: i < col2.length - 1, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 5 } }));
tocSlide.addText(col1Items, { x: 0.45, y: 1.1, w: 4.5, h: 4.3, valign: "top" });
tocSlide.addText(col2Items, { x: 5.2, y: 1.1, w: 4.5, h: 4.3, valign: "top" });

// Slide 3: Introduction
addContentSlide(pres, "Introduction & Definition", [
  "Infective Endocarditis (IE) is a microbial infection of the heart valves or endocardium",
  "Leads to formation of VEGETATIONS: composed of thrombotic debris, organisms, and fibrin",
  "Can affect native valves, prosthetic valves, endocardial surface, and great vessels",
  "Aortic aneurysmal sacs, other blood vessels, and prosthetic devices may also be infected",
  "Most cases caused by bacteria; fungi, rickettsiae, and chlamydial species can also cause IE",
  "A potentially life-threatening condition requiring urgent multi-disciplinary management",
  "Reference: Robbins & Kumar Basic Pathology; Ghai Essential Pediatrics"
]);

// Slide 4: Epidemiology
addContentSlide(pres, "Epidemiology", [
  "Annual incidence: 3–10 cases per 100,000 person-years in developed countries",
  "Rising incidence due to: aging population, more prosthetic valve implants, IV drug use",
  "More common in males (2:1 male-to-female ratio)",
  "Mean age of presentation has risen to 50–60 years in developed countries",
  "In developing countries (including India): still common in younger patients with RHD",
  "Mortality remains 15–30% despite modern therapy",
  "Right-sided IE: associated with IV drug users; left-sided more common overall",
  "Healthcare-associated IE now accounts for 25–30% of cases in developed nations"
]);

// Slide 5: Etiology
addTwoColumnSlide(pres,
  "Etiology - Causative Organisms",
  "Left-Sided / Native Valve",
  [
    "Streptococcus viridans (oral flora) - 50-60% community-acquired",
    "Staphylococcus aureus - most common in healthcare settings",
    "Streptococcus bovis - associated with colonic pathology",
    "Enterococcus species",
    "HACEK group organisms (Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella)",
    "Gram-negative bacilli (rare)"
  ],
  "Special Situations",
  [
    "Prosthetic valve (early <2 mo): Staph. epidermidis, S. aureus",
    "Prosthetic valve (late >2 mo): viridans streptococci",
    "IV drug users: S. aureus, Pseudomonas, Candida",
    "Q fever: Coxiella burnetii",
    "Culture-negative IE: ~10% of all cases",
    "Fungi: Candida, Aspergillus (immunocompromised)"
  ]
);

// Slide 6: Risk Factors
addTwoColumnSlide(pres,
  "Risk Factors for Infective Endocarditis",
  "Cardiac Risk Factors",
  [
    "Rheumatic heart disease (major in India)",
    "Congenital heart disease (CHD) - esp. cyanotic CHD",
    "Mitral valve prolapse with regurgitation",
    "Bicuspid aortic valve",
    "Prosthetic heart valves (10-20% of all IE)",
    "Previous infective endocarditis",
    "Hypertrophic obstructive cardiomyopathy"
  ],
  "Non-Cardiac Risk Factors",
  [
    "Intravenous drug use (IVDU)",
    "Indwelling catheters / pacemaker leads",
    "Poor dental hygiene / invasive dental procedures",
    "Hemodialysis",
    "Immunosuppression (HIV, diabetes, malignancy)",
    "Chronic alcohol use",
    "Elderly age"
  ]
);

// Slide 7: Pathogenesis
addContentSlide(pres, "Pathogenesis of Infective Endocarditis", [
  "STEP 1: Endothelial damage - turbulent blood flow causes microtrauma to valve endothelium",
  "STEP 2: Non-bacterial thrombotic endocarditis (NBTE) - sterile platelet-fibrin thrombus forms at damaged site",
  "STEP 3: Bacteremia - bacteria enter bloodstream (dental procedures, IV drug use, catheters, gut/oral flora)",
  "STEP 4: Bacterial adherence - organisms adhere to NBTE via surface adhesins (fibronectin-binding proteins)",
  "STEP 5: Vegetation formation - bacteria proliferate within fibrin mesh, evading host defenses",
  "STEP 6: Complications - local tissue destruction, embolic events, immune-complex deposition",
  "Key virulence: S. aureus produces dextran, fibronectin-binding proteins enabling direct valve attachment",
  "Ref: Robbins & Kumar Pathology; Braunwald's Heart Disease"
]);

// Slide 8: Classification
addTwoColumnSlide(pres,
  "Classification of Infective Endocarditis",
  "Acute IE",
  [
    "Rapid, destructive infection",
    "High-virulence organisms (e.g., S. aureus)",
    "Can attack previously NORMAL valves",
    "Fulminant course over days to weeks",
    "High morbidity and mortality even with treatment",
    "Commonly presents with septic emboli, fever, new murmur"
  ],
  "Subacute IE",
  [
    "Indolent onset, weeks to months",
    "Low-virulence organisms (e.g., viridans streptococci)",
    "Usually requires pre-existing valve abnormality",
    "Protracted course; most recover with antibiotics",
    "Classic 'SBE' (Subacute Bacterial Endocarditis)",
    "Common in rheumatic and congenital heart disease"
  ]
);

// Slide 9: Clinical Features
addContentSlide(pres, "Clinical Features", [
  "FEVER: Most common symptom; present in >90% of patients",
  "CHILLS, night sweats, malaise, anorexia, weight loss",
  "NEW or CHANGING CARDIAC MURMUR: aortic > mitral > tricuspid",
  "HEART FAILURE: Most common cause of death; due to valve destruction",
  "EMBOLIC EVENTS: Brain (stroke), spleen, kidneys, lungs (in right-sided IE)",
  "SPLENOMEGALY: present in subacute IE (20-57%)",
  "ARTHRALGIA / MYALGIA",
  "BACK PAIN: may indicate vertebral osteomyelitis complication",
  "In children: often fever with underlying CHD and new murmur (Ref: Ghai Essential Pediatrics)"
]);

// Slide 10: Peripheral Manifestations (with image)
const janeSlide = pres.addSlide();
janeSlide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: "F5F9FC" } });
janeSlide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: ACCENT2 } });
janeSlide.addShape(pres.ShapeType.rect, { x: 0.18, y: 0, w: 9.82, h: 0.95, fill: { color: DARK_BG } });
janeSlide.addText("Peripheral Manifestations", { x: 0.35, y: 0.08, w: 9.4, h: 0.75, fontSize: 22, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri" });
// Image - Janeway lesions (hand)
if (images[0] && images[0].base64) {
  janeSlide.addImage({ data: images[0].base64, x: 0.35, y: 1.05, w: 3.8, h: 3.2 });
  janeSlide.addShape(pres.ShapeType.rect, { x: 0.35, y: 4.25, w: 3.8, h: 0.4, fill: { color: DARK_BG } });
  janeSlide.addText("Janeway Lesions - painless hemorrhagic macules on palms/soles", { x: 0.35, y: 4.25, w: 3.8, h: 0.4, fontSize: 9, color: WHITE, align: "center", italic: true, fontFace: "Calibri" });
}
const periItems = [
  { text: "Janeway Lesions: painless, hemorrhagic macules on palms/soles (embolic)", options: { bullet: { code: "2022" }, breakLine: true, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } },
  { text: "Osler's Nodes: painful nodules on fingertips/toes (immune complex)", options: { bullet: { code: "2022" }, breakLine: true, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } },
  { text: "Splinter Hemorrhages: subungual linear hemorrhages", options: { bullet: { code: "2022" }, breakLine: true, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } },
  { text: "Roth Spots: oval retinal hemorrhages with pale centers", options: { bullet: { code: "2022" }, breakLine: true, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } },
  { text: "Petechiae: conjunctival, buccal mucosa", options: { bullet: { code: "2022" }, breakLine: true, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } },
  { text: "Clubbing: in chronic IE", options: { bullet: { code: "2022" }, breakLine: false, fontSize: 13.5, color: DARK_TEXT, fontFace: "Calibri", paraSpaceBefore: 4 } },
];
janeSlide.addText(periItems, { x: 4.4, y: 1.05, w: 5.35, h: 4.45, valign: "top" });

// Slide 11: Echocardiography (with echo image)
addImageSlide(pres,
  "Echocardiography in IE",
  images[6] || images[1],
  "Echo showing vegetation (VEG) on tricuspid valve - RV: Right Ventricle, LV: Left Ventricle, RA: Right Atrium",
  [
    "TTE (Transthoracic Echo): First-line investigation",
    "TEE (Transesophageal Echo): Higher sensitivity (90-100%) vs TTE (60-75%)",
    "TEE indicated: prosthetic valve, poor TTE quality, high clinical suspicion",
    "Vegetation: mobile, echogenic mass on valve leaflet",
    "Can detect: abscess, valvular perforation, pseudoaneurysm, fistula",
    "Serial echo to monitor vegetation size and treatment response",
    "Vegetation >10mm: higher embolic risk, consider surgery",
    "Ref: Textbook of Clinical Echocardiography, 2023 Duke Criteria"
  ]
);

// Slide 12: Duke Criteria - Major
addContentSlide(pres, "Duke Criteria for Diagnosis - Major Criteria", [
  "MICROBIOLOGICAL MAJOR CRITERIA:",
  "  • Typical organism from 2 separate blood cultures (viridans strep, S. bovis, HACEK, S. aureus, enterococcus)",
  "  • Persistently positive blood cultures (≥2 positive cultures >12 hours apart)",
  "  • Single positive blood culture for Coxiella burnetii or anti-phase I IgG antibody titer >1:800",
  "IMAGING MAJOR CRITERIA (echo/CT):",
  "  • Vegetation, leaflet perforation/aneurysm, abscess, pseudoaneurysm, intracardiac fistula",
  "  • New significant valvular regurgitation",
  "  • New partial dehiscence of prosthetic valve",
  "  • Abnormal 18F-FDG PET/CT activity around native/prosthetic valve",
  "SURGICAL MAJOR CRITERION:",
  "  • Evidence of IE observed by direct inspection during cardiac surgery"
]);

// Slide 13: Duke Criteria - Minor + Classification
addContentSlide(pres, "Duke Criteria - Minor Criteria & Classification", [
  "MINOR CRITERIA:",
  "  • Predisposition: previous IE, prosthetic valve, CHD, IVDU, injection drug use",
  "  • Fever: temperature ≥38°C (100.4°F)",
  "  • Vascular phenomena: arterial emboli, septic pulmonary infarcts, Janeway lesions, mycotic aneurysm",
  "  • Immunologic phenomena: Osler's nodes, Roth's spots, positive rheumatoid factor, GN",
  "  • Microbiological evidence not meeting major criterion",
  "CLASSIFICATION:",
  "  • DEFINITE IE: 2 major; OR 1 major + 3 minor; OR 5 minor criteria",
  "  • POSSIBLE IE: 1 major + 1 minor; OR 3 minor criteria",
  "  • REJECTED: Firm alternate diagnosis; resolution ≤4 days antibiotics; no pathological evidence",
  "  [2023 Duke-ISCVID Updated Criteria - Clin Infect Dis 77:518, 2023]"
]);

// Slide 14: Investigations
addContentSlide(pres, "Investigations", [
  "BLOOD CULTURES: Most important - minimum 3 sets from different sites before antibiotics",
  "CBC: leukocytosis, normocytic normochromic anemia, thrombocytopenia",
  "ESR & CRP: markedly elevated; useful for monitoring response",
  "Rheumatoid factor: positive in 50% of subacute IE (immune complex formation)",
  "Urinalysis: microscopic hematuria, proteinuria, RBC casts (immune complex glomerulonephritis)",
  "Chest X-ray: cardiomegaly, pulmonary edema, multiple embolic infarcts (right-sided IE)",
  "ECG: new AV block suggests perivalvular abscess extension",
  "CT/MRI brain: for embolic stroke, mycotic aneurysm detection",
  "PET-CT (18F-FDG): useful for prosthetic valve IE and device-related IE"
]);

// Slide 15: Osler Nodes & Roth Spots image slide
addImageSlide(pres,
  "Osler's Nodes - Physical Finding in IE",
  images[2],
  "Osler's nodes: painful, tender nodules on finger pulps (immune complex mediated)",
  [
    "OSLER'S NODES:",
    "  • Painful, tender nodules on fingertips and toes",
    "  • Caused by immune complex deposition",
    "  • More common in subacute IE",
    "  • Transient; resolve with treatment",
    "ROTH SPOTS:",
    "  • Oval retinal hemorrhages with white/pale centers",
    "  • Found on fundoscopy",
    "  • Also seen in leukemia, anemia, hypertension",
    "  • Caused by septic emboli to retinal vessels"
  ]
);

// Slide 16: Management - Antibiotics
addContentSlide(pres, "Management - Antibiotic Therapy", [
  "Principles: bactericidal antibiotics, parenteral route, prolonged duration (4-6 weeks)",
  "Blood cultures MUST be drawn before starting antibiotics",
  "EMPIRICAL THERAPY (before culture): Vancomycin + Gentamicin (if prosthetic) or Ampicillin-Sulbactam",
  "VIRIDANS STREPTOCOCCI: IV Penicillin G or Ceftriaxone x 4 weeks; add Gentamicin for synergy",
  "STAPHYLOCOCCUS AUREUS (MSSA): Nafcillin/Oxacillin x 6 weeks",
  "STAPHYLOCOCCUS AUREUS (MRSA): Vancomycin or Daptomycin x 6 weeks",
  "ENTEROCOCCUS: Ampicillin + Gentamicin x 4-6 weeks",
  "Q FEVER (Coxiella): Doxycycline + Hydroxychloroquine x 18 months",
  "FUNGI: Amphotericin B + surgical valve replacement usually required"
]);

// Slide 17: Management - Antibiotic Table
addTableSlide(pres, "Antibiotic Prophylaxis - High Risk Conditions (AHA 2021)",
  ["High-Risk Condition", "Details"],
  [
    ["Prosthetic cardiac valve", "Mechanical, bioprosthetic, or transcatheter-implanted valves"],
    ["Previous IE", "Any prior episode of infective endocarditis"],
    ["Cyanotic congenital heart disease", "Unrepaired CHD including palliative shunts and conduits"],
    ["Repaired CHD with prosthetic material", "Within 6 months after repair"],
    ["Repaired CHD with residual defects", "At or adjacent to prosthetic patch/device"],
    ["Cardiac transplant with valvulopathy", "Valvular regurgitation due to structurally abnormal valve"],
    ["Ventricular assist devices", "Included in 2021 AHA update as high risk"],
    ["Preferred prophylaxis antibiotic", "Amoxicillin 2g PO 30-60 min before dental procedure"]
  ]
);

// Slide 18: Indications for Surgery
addContentSlide(pres, "Indications for Surgical Intervention", [
  "URGENT/EMERGENT SURGERY (within 24-48 hours):",
  "  • Acute severe AR or MR with hemodynamic instability/pulmonary edema",
  "  • Septic shock due to valve dysfunction refractory to medical therapy",
  "  • Aortic or mitral IE with fistula/abscess causing hemodynamic compromise",
  "EARLY SURGERY (within 7 days):",
  "  • Vegetation >10mm with systemic embolism during antibiotic therapy",
  "  • Severe valve dysfunction with NYHA Class III/IV heart failure",
  "  • Periannular abscess or destructive penetrating lesions",
  "  • Persistent bacteremia after 5-7 days of appropriate antibiotics",
  "  • Fungal or highly resistant organism endocarditis",
  "Ref: Braunwald's Heart Disease; AHA/ACC Valve Guidelines 2021"
]);

// Slide 19: Complications
addTwoColumnSlide(pres,
  "Complications of Infective Endocarditis",
  "Cardiac Complications",
  [
    "Heart failure (most common cause of death)",
    "Perivalvular abscess (aortic root most common)",
    "Valvular destruction with acute AR or MR",
    "Conduction abnormalities / AV block",
    "Purulent pericarditis",
    "Myocardial infarction (coronary artery embolism)",
    "Fistulae (aorta-left atrium, etc.)"
  ],
  "Extra-Cardiac Complications",
  [
    "CNS: embolic stroke, cerebral abscess, mycotic aneurysm, meningitis",
    "Splenic abscess or infarction",
    "Renal: immune complex GN, renal abscess, renal infarction",
    "Metastatic abscesses: liver, bone, joints",
    "Pulmonary emboli (right-sided IE)",
    "Mycotic aneurysms (particularly intracranial)",
    "Musculoskeletal: vertebral osteomyelitis"
  ]
);

// Slide 20: IE in Children (Ghai reference)
addContentSlide(pres, "IE in Children - Ghai Essential Pediatrics Reference", [
  "Children with CHD are at significant risk for infective endocarditis",
  "Most common predisposing conditions in children: CHD (esp. VSD, PDA, TOF, bicuspid aortic valve)",
  "Historically common with rheumatic heart disease; now more with CHD (corrected and uncorrected)",
  "Clinical presentation: unexplained fever, changing/worsening cardiac murmur",
  "Neonatal IE: S. aureus, gram-negative organisms; associated with umbilical/central catheters",
  "Diagnosis using modified Duke criteria - same as adults",
  "Blood culture is the KEY investigation; echocardiography essential",
  "Treatment: IV antibiotics for 4-6 weeks; surgery for complications",
  "Prevention: antibiotic prophylaxis before dental procedures in high-risk CHD (AHA 2021)",
  "Ref: Ghai Essential Pediatrics, Chapter on Cardiovascular Diseases"
]);

// Slide 21: Vegetation - Image slide
addImageSlide(pres,
  "Echocardiographic Vegetation - Key Diagnostic Feature",
  images[1],
  "Echocardiogram showing vegetation (VEG) on tricuspid valve (Medbullets/Educational Use)",
  [
    "Vegetation characteristics:",
    "  • Irregular, echo-dense mobile mass on valve leaflet",
    "  • Typically on atrial side of AV valves",
    "  • On ventricular side of semilunar valves",
    "  • Size range: 2mm to >2cm",
    "Size and risk:",
    "  • >10mm: high embolic risk",
    "  • >15mm: very high embolic risk",
    "  • Mobile vegetations more prone to embolize",
    "Serial echo every 5-7 days in active IE to monitor changes"
  ]
);

// Slide 22: Pathology of Vegetations
addContentSlide(pres, "Pathology of Vegetations", [
  "Vegetations = masses of thrombotic debris + microorganisms + fibrin + inflammatory cells",
  "ACUTE IE vegetations: large, bulky, destructive; valve leaflet perforation common",
  "SUBACUTE IE vegetations: smaller, less destructive; valvular deformity",
  "Microscopically: colonies of bacteria embedded in fibrin/platelet mesh; WBC infiltration",
  "Vegetations lack intrinsic blood supply - explains why antibiotics must be bactericidal",
  "High bacterial burden within vegetations (up to 10^9-10^11 colony forming units/gram)",
  "Healing: fibrosis, calcification, or scar formation after successful treatment",
  "Sterile vegetations: can persist for months after cure (not indicator of active disease)",
  "Ref: Robbins & Kumar Basic Pathology; Robbins Cotran & Kumar Pathologic Basis of Disease"
]);

// Slide 23: Right-sided vs Left-sided IE
addTwoColumnSlide(pres,
  "Left-Sided vs Right-Sided IE",
  "Left-Sided IE",
  [
    "More common (accounts for majority of IE cases)",
    "Involves mitral and/or aortic valves",
    "Common in: RHD, CHD, prosthetic valves, elderly",
    "Complications: stroke, systemic emboli, heart failure, renal infarction, splenic abscess",
    "Organisms: viridans streptococci (community), S. aureus (healthcare)",
    "Requires 4-6 weeks of IV antibiotics"
  ],
  "Right-Sided IE",
  [
    "Less common; strongly associated with IV drug use",
    "Involves tricuspid valve (most common), pulmonary valve (rare)",
    "Organisms: S. aureus predominates (>75%)",
    "Complications: septic pulmonary emboli, pneumonia, empyema",
    "Better prognosis than left-sided IE",
    "May respond to shorter courses (2 weeks) in uncomplicated IVDU-associated IE"
  ]
);

// Slide 24: Special Situations - Prosthetic Valve IE
addContentSlide(pres, "Prosthetic Valve Endocarditis (PVE)", [
  "Accounts for 10-20% of all cases of IE",
  "EARLY PVE (<2 months post-surgery): Staph. epidermidis, S. aureus, gram-negatives, fungi",
  "  - Source: perioperative contamination",
  "LATE PVE (>2 months post-surgery): similar to native valve IE; viridans streptococci common",
  "Clinical presentation: often insidious; fever, new or changing murmur, signs of valve dysfunction",
  "Diagnosis: TEE preferred (TTE less sensitive for prosthetic valves)",
  "PET-CT/nuclear imaging valuable when echo is inconclusive",
  "Treatment: longer antibiotic courses; rifampicin added for Staphylococcal PVE",
  "Surgery often required: valve dehiscence, paravalvular leak, abscess formation"
]);

// Slide 25: Splinter Hemorrhages image slide
addImageSlide(pres,
  "Splinter Hemorrhages & Peripheral Signs",
  images[4],
  "Splinter hemorrhages: linear, dark-red subungual hemorrhages",
  [
    "SPLINTER HEMORRHAGES:",
    "  • Linear subungual hemorrhages, distal to proximal direction",
    "  • Found under fingernails or toenails",
    "  • Caused by microemboli to nail bed vasculature",
    "  • Not specific - also in trauma, vasculitis",
    "PETECHIAE:",
    "  • Small, flat, non-blanching red spots",
    "  • Found on conjunctivae, buccal mucosa, skin",
    "  • From septic micro-emboli",
    "CLUBBING: Digital clubbing in prolonged/chronic IE"
  ]
);

// Slide 26: Prevention
addContentSlide(pres, "Prevention of Infective Endocarditis", [
  "AHA 2021 Scientific Statement updates prophylaxis guidelines",
  "Antibiotic prophylaxis (AP) recommended for HIGH-RISK patients undergoing INVASIVE DENTAL procedures",
  "Preferred regimen: Amoxicillin 2g PO (adults); 50mg/kg PO (children) 30-60 min before procedure",
  "Penicillin allergy: Azithromycin 500mg PO OR Clindamycin NOT recommended (C. diff risk)",
  "Alternatives in penicillin allergy: Doxycycline now added as option (2021 update)",
  "NON-DENTAL procedures: routine prophylaxis NOT recommended (GI, GU, respiratory procedures)",
  "General preventive measures:",
  "  • Strict aseptic technique for IV catheters and pacemaker insertion",
  "  • Good oral hygiene and regular dental care",
  "  • Avoid IV drug use; use needle exchange programs",
  "  • Prompt treatment of skin and soft tissue infections"
]);

// Slide 27: Prognosis & Outcomes
addContentSlide(pres, "Prognosis & Outcomes", [
  "In-hospital mortality: 15-20%; one-year mortality: 20-30% despite treatment",
  "Mortality predictors: older age, comorbidities, S. aureus, prosthetic valve, complicated IE",
  "HEART FAILURE: single most important predictor of poor prognosis",
  "Embolic events: 20-50% of patients; mostly cerebral (brain MRI detects occult emboli in 60%)",
  "Recurrence rate: ~10% in surgically treated patients, higher with IVDU",
  "Surgical outcomes: operative mortality 10-20%; 5-year survival 60-80%",
  "Good prognostic factors: viridans streptococcal IE, right-sided IE, no complications",
  "Poor prognostic factors: S. aureus, fungal IE, intracardiac abscess, prosthetic valve, stroke",
  "Regular follow-up: echo at 1, 3, 6 months post-treatment",
  "Ref: Braunwald's Heart Disease; Harrison's Principles of Internal Medicine 22E (2025)"
]);

// Slide 28: Thank You
addThankYouSlide(pres);

// Write file
pres.writeFile({ fileName: "/home/daytona/workspace/ie-ppt/Infective_Endocarditis.pptx" })
  .then(() => console.log("PPT created successfully!"))
  .catch(err => console.error("Error creating PPT:", err));

cd /home/daytona/workspace/ie-ppt && node build_ie_ppt.js 2>&1

cd /home/daytona/workspace/ie-ppt && \ wget -q "https://upload.medbullets.com/to…

~/ie-ppt/build_ie_ppt_v2.js

const pptxgen = require("pptxgenjs");
const fs = require("fs");
const path = require("path");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Infective Endocarditis";
pres.author = "Medical Education";

// Color palette
const DARK_BG = "0D2137";
const ACCENT = "C0392B";
const ACCENT2 = "E74C3C";
const WHITE = "FFFFFF";
const DARK_TEXT = "1A2530";
const TEAL = "117A8B";
const YELLOW_ACC = "F39C12";

// Load local images
const imgDir = "/home/daytona/workspace/ie-ppt/";
function loadImg(fname) {
  const fpath = path.join(imgDir, fname);
  if (fs.existsSync(fpath)) {
    const ext = path.extname(fname).slice(1).toLowerCase();
    const mime = ext === "jpg" ? "jpeg" : ext;
    const data = fs.readFileSync(fpath).toString("base64");
    return `image/${mime};base64,${data}`;
  }
  return null;
}

const imgJaneway = loadImg("img_janeway.jpg");
const imgEcho = loadImg("img_echo.jpg");
const imgOsler = loadImg("img_osler.jpg");
const imgSplinter = loadImg("img_splinter.jpg");

console.log("Images loaded:", {janeway: !!imgJaneway, echo: !!imgEcho, osler: !!imgOsler, splinter: !!imgSplinter});

// ============================================================
// HELPER FUNCTIONS
// ============================================================

function addTitleSlide(pres) {
  const slide = pres.addSlide();
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: DARK_BG } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 4.35, w: 10, h: 0.12, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.08, fill: { color: ACCENT } });
  slide.addShape(pres.ShapeType.ellipse, { x: 4.2, y: 0.55, w: 1.6, h: 1.6, fill: { color: ACCENT }, line: { color: ACCENT2, width: 2 } });
  slide.addText("♥", { x: 4.2, y: 0.65, w: 1.6, h: 1.2, fontSize: 36, color: WHITE, align: "center", bold: true });
  slide.addText("INFECTIVE ENDOCARDITIS", {
    x: 0.5, y: 2.35, w: 9, h: 0.9,
    fontSize: 36, bold: true, color: WHITE, align: "center", charSpacing: 3, fontFace: "Calibri"
  });
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  slide.addText("A Comprehensive Overview", {
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    fontSize: 18, italic: true, color: "A8D8EA", align: "center", fontFace: "Calibri"
  });
  slide.addText("Reference: Ghai Essential Pediatrics  |  Robbins & Kumar Pathology  |  Braunwald's Heart Disease", {
    x: 0.5, y: 4.45, w: 9, h: 0.4,
    fontSize: 10, color: "A0B4C0", align: "center", fontFace: "Calibri"
  });
}

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}

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function addTableSlide(pres, title, headers, rows, accentColor) {
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}

function addThankYouSlide(pres) {
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  slide.addText("THANK YOU", { x: 1, y: 1.85, w: 8, h: 1.1, fontSize: 50, bold: true, color: WHITE, align: "center", charSpacing: 8, fontFace: "Calibri" });
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    fontSize: 16, italic: true, color: "A8D8EA", align: "center", fontFace: "Calibri"
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  slide.addText("References:\nGhai Essential Pediatrics  |  Robbins & Kumar Basic Pathology\nBraunwald's Heart Disease  |  Harrison's Principles of Internal Medicine 22E (2025)\nTextbook of Clinical Echocardiography  |  AHA Guidelines 2021", {
    x: 1, y: 3.9, w: 8, h: 1.2,
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// ============================================================
// BUILD 28 SLIDES
// ============================================================

// SLIDE 1: Title
addTitleSlide(pres);

// SLIDE 2: Table of Contents
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  const slide = pres.addSlide();
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  const col1 = ["1. Introduction & Definition","2. Epidemiology","3. Etiology - Causative Organisms","4. Risk Factors","5. Pathogenesis","6. Classification","7. Clinical Features"];
  const col2 = ["8. Peripheral Manifestations","9. Echocardiography","10. Duke Criteria (Major)","11. Duke Criteria (Minor)","12. Investigations","13. Management - Antibiotics","14. Antibiotic Prophylaxis Table"];
  const col3 = ["15. Surgery Indications","16. Complications","17. IE in Children (Ghai)","18. Pathology of Vegetations","19. Right vs Left-sided IE","20. Prosthetic Valve IE","21. Prevention | Prognosis"];
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// SLIDE 3: Introduction
addContentSlide(pres, "Introduction & Definition", [
  "Infective Endocarditis (IE): microbial infection of the heart valves or endocardium",
  "Results in formation of VEGETATIONS - masses of fibrin, platelets, organisms, and necrotic tissue",
  "Can affect native valves, prosthetic valves, endocardial surface, and great vessels",
  "Also infects: aortic aneurysmal sacs, other blood vessels, and intracardiac prosthetic devices",
  "Causative agents: bacteria (majority); also fungi, rickettsiae, chlamydial species",
  "IE classified as ACUTE (rapid, destructive) or SUBACUTE (indolent, protracted)",
  "Potentially fatal if untreated; requires multidisciplinary team management",
  "Reference: Ghai Essential Pediatrics; Robbins & Kumar Basic Pathology (p.368)"
]);

// SLIDE 4: Epidemiology
addContentSlide(pres, "Epidemiology", [
  "Annual incidence: 3-10 per 100,000 person-years in developed countries",
  "Incidence rising due to: aging population, more prosthetic valves, IV drug use epidemic",
  "Male predominance: approximately 2:1 male-to-female ratio",
  "Mean age has shifted upward - now 50-60 years in developed nations",
  "In India & developing countries: still common in young adults due to rheumatic heart disease (RHD)",
  "Mortality: 15-30% in-hospital despite modern antibiotic therapy and surgery",
  "Healthcare-associated IE: accounts for 25-30% of cases in developed nations",
  "Right-sided IE: strongly associated with IV drug use; tricuspid valve most commonly affected"
]);

// SLIDE 5: Etiology
addTwoColumnSlide(pres, "Etiology - Causative Organisms",
  "Common Organisms",
  [
    "Streptococcus viridans: 50-60% of community-acquired IE; oral flora; subacute",
    "Staphylococcus aureus: #1 in healthcare/IVDU; can infect normal valves; acute",
    "Streptococcus bovis: associated with colonic malignancy",
    "Enterococcus species: urological or GI portals of entry",
    "HACEK group: Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella",
    "Fungi: Candida, Aspergillus (immunocompromised)"
  ],
  "Special Situations",
  [
    "Prosthetic valve early (<2 mo): Staph. epidermidis, S. aureus, gram-negatives",
    "Prosthetic valve late (>2 mo): viridans streptococci, similar to native valve",
    "IV drug users: S. aureus, Pseudomonas, Candida",
    "Q fever endocarditis: Coxiella burnetii (chronic, culture-negative)",
    "Culture-negative IE: ~10% of all cases (prior antibiotics, fastidious organisms)",
    "Gram-negative bacilli: rare; poor prognosis"
  ]
);

// SLIDE 6: Risk Factors
addTwoColumnSlide(pres, "Risk Factors for IE",
  "Cardiac Risk Factors",
  [
    "Rheumatic heart disease (major risk in India/developing countries)",
    "Congenital heart disease - esp. cyanotic CHD, VSD, PDA, TOF",
    "Mitral valve prolapse with regurgitation",
    "Bicuspid aortic valve",
    "Prosthetic heart valves (10-20% of all IE)",
    "Previous infective endocarditis (recurrence ~10%)",
    "Hypertrophic obstructive cardiomyopathy"
  ],
  "Non-Cardiac Risk Factors",
  [
    "IV drug use (IVDU) - opioid epidemic driving rise in IE",
    "Indwelling vascular catheters / pacemaker leads",
    "Poor dental hygiene; invasive dental procedures",
    "Hemodialysis (arteriovenous fistula or tunneled catheter)",
    "Immunosuppression: HIV, diabetes, malignancy, steroids",
    "Chronic alcohol use",
    "Elderly age with degenerative valve disease"
  ]
);

// SLIDE 7: Pathogenesis
addContentSlide(pres, "Pathogenesis of Infective Endocarditis", [
  "STEP 1 - Endothelial Damage: turbulent blood flow from abnormal valves causes micro-injury",
  "STEP 2 - NBTE Formation: sterile platelet-fibrin thrombus (Non-Bacterial Thrombotic Endocarditis) deposits on damaged endothelium",
  "STEP 3 - Bacteremia: organisms enter bloodstream via dental procedures, IV drug use, catheters, gut/oral flora",
  "STEP 4 - Bacterial Adherence: organisms bind to NBTE via surface adhesins (fibronectin-binding proteins, dextran)",
  "STEP 5 - Vegetation Growth: bacteria proliferate within fibrin mesh, protected from host phagocytes",
  "STEP 6 - Tissue Destruction: proteases and toxins destroy valve tissue; perivalvular spread",
  "STEP 7 - Complications: emboli fragment and migrate; immune complexes deposit in kidneys, joints",
  "Key point: High bacterial density (10^9-11 CFU/g) in vegetations necessitates bactericidal antibiotics"
]);

// SLIDE 8: Classification
addTwoColumnSlide(pres, "Classification of Infective Endocarditis",
  "Acute Infective Endocarditis",
  [
    "Rapid, destructive infection (days to weeks)",
    "High-virulence organisms: S. aureus most common",
    "Attacks previously NORMAL valves",
    "Fulminant systemic sepsis common",
    "High morbidity and mortality even with treatment",
    "Septic emboli and metastatic abscesses frequent",
    "Often requires emergency surgery"
  ],
  "Subacute Infective Endocarditis",
  [
    "Insidious onset; weeks to months course",
    "Low-virulence organisms: viridans streptococci",
    "Requires pre-existing valve abnormality (RHD, CHD, MVP)",
    "Classic 'SBE' - Subacute Bacterial Endocarditis",
    "Immune manifestations prominent (Osler's nodes, Roth spots)",
    "Most patients recover with appropriate antibiotics",
    "Good prognostic response to antibiotic therapy"
  ]
);

// SLIDE 9: Clinical Features
addContentSlide(pres, "Clinical Features", [
  "FEVER: Most common symptom; present in >90%; may be low-grade or absent in elderly/immunosuppressed",
  "CONSTITUTIONAL: chills, night sweats, malaise, fatigue, anorexia, weight loss",
  "CARDIAC MURMUR: new or changing murmur (present in ~85%); aortic most commonly affected valve",
  "HEART FAILURE: most common cause of death; due to valve destruction (AR or MR)",
  "EMBOLIC PHENOMENA: brain (stroke ~20%), spleen, kidneys, lungs (in right-sided IE)",
  "SPLENOMEGALY: present in 20-57% of subacute IE cases",
  "ARTHRALGIA / MYALGIA / BACK PAIN",
  "NEUROLOGICAL: headache, stroke, altered sensorium (from cerebral emboli or mycotic aneurysm)",
  "In children: fever + CHD + worsening murmur - always suspect IE (Ref: Ghai Essential Pediatrics)"
]);

// SLIDE 10: Peripheral Manifestations with image
addImageSlide(pres,
  "Peripheral Manifestations - Janeway Lesions",
  imgJaneway,
  "Janeway Lesions: painless hemorrhagic macules on palms/soles (embolic, pathognomonic of acute IE)",
  [
    "JANEWAY LESIONS:",
    "  Painless hemorrhagic macules on palms and soles",
    "  Caused by septic microemboli; pathognomonic for acute IE",
    "OSLER'S NODES:",
    "  Painful, tender subcutaneous nodules on fingertips/toes",
    "  Immune complex mediated; more common in subacute IE",
    "SPLINTER HEMORRHAGES:",
    "  Linear subungual hemorrhages; from microemboli",
    "ROTH SPOTS:",
    "  Oval retinal hemorrhages with white centers on fundoscopy",
    "PETECHIAE:",
    "  Conjunctival, buccal mucosa; non-blanching"
  ],
  false
);

// SLIDE 11: Echocardiography
addImageSlide(pres,
  "Echocardiography - Key Diagnostic Tool",
  imgEcho,
  "Echo: VEG = Vegetation on valve; RV = Right Ventricle, LV = Left Ventricle, RA = Right Atrium",
  [
    "TTE (Transthoracic Echo): first-line investigation; sensitivity 60-75%",
    "TEE (Transesophageal Echo): sensitivity 90-100%; preferred when:",
    "  Prosthetic valve; Poor TTE quality",
    "  High clinical suspicion despite negative TTE",
    "  Staphylococcal bacteremia",
    "ECHO FINDINGS:",
    "  Vegetation: mobile, echogenic mass on leaflet",
    "  Abscess: periannular echo-free space",
    "  Valve perforation; Fistula",
    "Vegetation >10mm: high embolic risk - consider early surgery",
    "Serial echo every 5-7 days to monitor response"
  ],
  true
);

// SLIDE 12: Duke Criteria Major
addContentSlide(pres, "Duke Criteria (2023 Updated) - Major Criteria", [
  "MICROBIOLOGICAL MAJOR CRITERIA:",
  "  Typical IE organism from 2 separate blood cultures (viridans strep, S. bovis, HACEK, S. aureus, enterococci)",
  "  Persistently +ve blood cultures: >=2 positive cultures drawn >12 hours apart",
  "  Single +ve culture for Coxiella burnetii OR anti-phase I IgG antibody titer >1:800",
  "IMAGING MAJOR CRITERIA (echo, CT, or PET-CT):",
  "  Vegetation / leaflet perforation / aneurysm / abscess / pseudoaneurysm / intracardiac fistula",
  "  New significant valvular regurgitation (new compared to prior imaging)",
  "  New partial dehiscence of prosthetic valve",
  "  Abnormal 18F-FDG PET/CT activity around native/prosthetic valve (>=3 months post-implant)",
  "SURGICAL MAJOR CRITERION:",
  "  Evidence of IE by direct inspection during cardiac surgery"
]);

// SLIDE 13: Duke Criteria Minor + Classification
addContentSlide(pres, "Duke Criteria - Minor Criteria & Diagnostic Classification", [
  "MINOR CRITERIA:",
  "  Predisposition: previous IE, prosthetic valve, CHD, IVDU, more than mild regurgitation/stenosis",
  "  Fever: temperature >=38 degrees C (100.4 degrees F)",
  "  Vascular phenomena: arterial emboli, septic pulmonary infarcts, Janeway lesions, mycotic aneurysm, intracranial hemorrhage",
  "  Immunologic phenomena: Osler nodes, Roth spots, positive rheumatoid factor, glomerulonephritis",
  "  Microbiological evidence not fulfilling major criterion",
  "DEFINITE IE: 2 Major; OR 1 Major + 3 Minor; OR 5 Minor",
  "POSSIBLE IE: 1 Major + 1 Minor; OR 3 Minor",
  "REJECTED: Firm alternate diagnosis; OR Resolution within 4 days of antibiotics",
  "Source: 2023 Duke-ISCVID Updated Criteria (Clin Infect Dis 77:518, 2023)"
]);

// SLIDE 14: Investigations
addContentSlide(pres, "Investigations", [
  "BLOOD CULTURES: Most critical - 3 sets from different sites, before antibiotics",
  "CBC: leukocytosis, normocytic normochromic anemia, thrombocytopenia",
  "ESR & CRP: markedly elevated; monitor treatment response",
  "Rheumatoid factor: positive in ~50% of subacute IE (immune complex deposition)",
  "Urinalysis: microscopic hematuria, proteinuria, RBC casts (immune complex GN)",
  "Chest X-ray: cardiomegaly, pulmonary edema; multiple cavitating opacities in right-sided IE",
  "ECG: new AV block / prolonged PR interval suggests perivalvular abscess",
  "CT/MRI Brain: embolic stroke, cerebral abscess, mycotic aneurysm",
  "PET-CT (18F-FDG): prosthetic valve IE; device-related IE where echo inconclusive"
]);

// SLIDE 15: Osler Nodes image
addImageSlide(pres,
  "Osler's Nodes - Immune Complex Manifestation",
  imgOsler,
  "Osler's nodes: painful, tender subcutaneous nodules on finger pulps (immune complex mediated)",
  [
    "OSLER'S NODES:",
    "  Painful, tender nodules on fingertips and toes",
    "  Due to immune complex deposition in vessel walls",
    "  Transient - resolve with treatment",
    "  More characteristic of SUBACUTE IE",
    "vs JANEWAY LESIONS:",
    "  Painless hemorrhagic macules - embolic",
    "  More characteristic of ACUTE IE",
    "MNEMONIC:",
    "  Osler's = pO (painful) - Old/subacute",
    "  Janeway = J (painless) = 'Just emboli'"
  ],
  false
);

// SLIDE 16: Management Antibiotics
addContentSlide(pres, "Management - Antibiotic Therapy", [
  "Principles: bactericidal drugs, parenteral (IV) route, prolonged duration 4-6 weeks",
  "Blood cultures MUST be drawn BEFORE starting antibiotics",
  "EMPIRICAL THERAPY (culture pending): Vancomycin + Ceftriaxone; cover S. aureus and streptococci",
  "VIRIDANS STREPTOCOCCI: IV Penicillin G or Ceftriaxone x 4 weeks (+/- Gentamicin for synergy 2 weeks)",
  "S. AUREUS MSSA: Nafcillin/Oxacillin (or Cloxacillin) x 6 weeks; Rifampicin for prosthetic valves",
  "S. AUREUS MRSA: Vancomycin OR Daptomycin x 6 weeks (Daptomycin preferred for right-sided IE)",
  "ENTEROCOCCUS: Ampicillin + Gentamicin x 4-6 weeks; or Ampicillin + Ceftriaxone",
  "Q FEVER (Coxiella): Doxycycline + Hydroxychloroquine x 18 months",
  "FUNGAL IE: Amphotericin B + azole consolidation; usually requires surgical valve replacement"
]);

// SLIDE 17: Prophylaxis table
addTableSlide(pres, "Antibiotic Prophylaxis - AHA 2021 Guidelines",
  ["High-Risk Condition", "Key Details"],
  [
    ["Prosthetic cardiac valve", "Mechanical, bioprosthetic, or transcatheter-implanted valves"],
    ["Previous infective endocarditis", "Any prior episode of IE"],
    ["Cyanotic congenital heart disease", "Unrepaired CHD including palliative shunts/conduits"],
    ["Repaired CHD with prosthetic material", "Within 6 months after surgical/catheter repair"],
    ["Repaired CHD with residual defects", "At or adjacent to prosthetic patch or device site"],
    ["Cardiac transplant with valvulopathy", "Structurally abnormal valve with regurgitation"],
    ["Ventricular assist devices", "NEW in 2021 AHA update - classified as high risk"],
    ["Preferred prophylactic antibiotic", "Amoxicillin 2g PO (adults) 30-60 min before dental procedure"],
    ["Penicillin allergy - alternative", "Azithromycin 500mg PO or Doxycycline (new 2021) - NOT Clindamycin"]
  ],
  TEAL
);

// SLIDE 18: Surgery indications
addContentSlide(pres, "Indications for Surgical Intervention", [
  "URGENT/EMERGENT (within 24-48 hours) - hemodynamic emergency:",
  "  Acute severe AR or MR with refractory pulmonary edema or cardiogenic shock",
  "  Septic shock due to valve dysfunction not responding to vasopressors",
  "  Aorto-cardiac fistula causing hemodynamic compromise",
  "EARLY SURGERY (within 7 days):",
  "  Vegetation >10mm with systemic embolism occurring during antibiotic therapy",
  "  Severe valve dysfunction with NYHA Class III/IV heart failure",
  "  Periannular abscess, pseudoaneurysm, destructive penetrating lesions",
  "  Persistent bacteremia >5-7 days despite adequate antibiotic therapy",
  "  Fungal IE or highly resistant organisms (MRSA, VRE, gram-negative)",
  "Ref: Braunwald's Heart Disease; Indications for and Timing of Surgery in IE"
]);

// SLIDE 19: Complications
addTwoColumnSlide(pres, "Complications of Infective Endocarditis",
  "Cardiac Complications",
  [
    "Heart failure: most common cause of death; from valve destruction (AR/MR)",
    "Perivalvular abscess: aortic root most common; new AV block is a clue",
    "Valve ring abscess and fistula formation",
    "Pericarditis / purulent pericardial effusion",
    "Coronary artery embolism causing MI",
    "Conduction system involvement: AV block, bundle branch block",
    "Myocarditis from direct extension"
  ],
  "Extracardiac Complications",
  [
    "CNS: embolic stroke (20-40%), cerebral abscess, mycotic aneurysm, meningitis",
    "Renal: immune complex GN, renal infarction, renal abscess",
    "Spleen: splenic infarction, splenic abscess",
    "Lung: septic pulmonary emboli (right-sided IE), pneumonia, empyema",
    "Musculoskeletal: vertebral osteomyelitis, septic arthritis",
    "Mycotic aneurysm: especially intracranial - risk of rupture and hemorrhage",
    "Metastatic abscesses: liver, bone, psoas muscle"
  ]
);

// SLIDE 20: IE in Children - Ghai
addContentSlide(pres, "IE in Children - Reference: Ghai Essential Pediatrics", [
  "Children with CHD are at significant risk for infective endocarditis",
  "Historically associated with rheumatic heart disease; now more with congenital heart disease",
  "Most common predisposing CHDs: VSD, PDA, TOF, bicuspid aortic valve, post-cardiac surgery",
  "Clinical features: unexplained prolonged fever + changing or new cardiac murmur",
  "Neonatal IE: S. aureus and gram-negative organisms common; linked to umbilical/central catheters",
  "Diagnosis: modified Duke criteria applied; echocardiography essential",
  "Blood culture is KEY - draw 3 sets before antibiotics",
  "Treatment: IV bactericidal antibiotics x 4-6 weeks; surgery for valve destruction or failed therapy",
  "Antibiotic prophylaxis: recommended before dental procedures for high-risk CHD (AHA 2021)",
  "Good outcomes when diagnosed early; complications include heart failure, stroke, valve destruction"
]);

// SLIDE 21: Vegetation image with echo
addImageSlide(pres,
  "Vegetation on Echo - Pathological Correlate",
  imgEcho,
  "Echocardiogram: Vegetation (VEG) seen as bright mobile mass near tricuspid valve",
  [
    "MORPHOLOGY of vegetation:",
    "  Irregular, friable, mobile echogenic mass",
    "  Attached to atrial surface of AV valves",
    "  Attached to ventricular surface of aortic/pulmonary valves",
    "SIZE and RISK:",
    "  <10mm: lower embolic risk, medical therapy",
    "  10-15mm: high embolic risk - close monitoring",
    "  >15mm: very high embolic risk - early surgery",
    "Histology: bacteria embedded in fibrin-platelet mesh with WBC infiltration",
    "Path: Robbins & Kumar Basic Pathology, p.368"
  ],
  false
);

// SLIDE 22: Pathology of Vegetations
addContentSlide(pres, "Pathology of Vegetations", [
  "Vegetations = thrombotic debris + microorganisms + fibrin + inflammatory cells + necrotic tissue",
  "ACUTE IE: Large, bulky, destructive vegetations; leaflet perforation common",
  "SUBACUTE IE: Smaller, less destructive; chronic valvular deformity",
  "Microscopically: colonies of bacteria embedded in fibrin/platelet mesh with WBC infiltration",
  "High bacterial density: 10^9 - 10^11 colony forming units per gram of vegetation",
  "Lack of intrinsic blood supply in vegetations: explains why bactericidal drugs are required",
  "Healing: fibrosis, calcification, scar formation after successful treatment",
  "Sterile vegetations may persist for months after microbiological cure",
  "Predilection: low-pressure side of regurgitant valve lesion (jet lesion effect)",
  "Ref: Robbins & Kumar Basic Pathology; Robbins Cotran & Kumar Pathologic Basis of Disease"
]);

// SLIDE 23: Right vs Left sided IE
addTwoColumnSlide(pres, "Left-Sided vs Right-Sided IE",
  "Left-Sided IE (Majority)",
  [
    "More common - accounts for majority of IE",
    "Involves mitral and/or aortic valves",
    "Common in: RHD, CHD, prosthetic valves, elderly",
    "Systemic emboli: stroke, renal infarction, splenic abscess",
    "Organisms: viridans strep (community); S. aureus (healthcare)",
    "Higher mortality: complications include acute AR/MR, heart failure",
    "4-6 weeks IV antibiotics required"
  ],
  "Right-Sided IE (IVDU-associated)",
  [
    "Less common; strongly linked to IV drug use",
    "Tricuspid valve most commonly affected (>75%)",
    "Predominantly S. aureus (>75% of IVDU-associated IE)",
    "Complications: septic pulmonary emboli, lung abscess, empyema",
    "Generally better prognosis than left-sided IE",
    "Shorter courses possible: 2 weeks in uncomplicated IVDU-tricuspid IE",
    "Oral antibiotics may be considered in selected patients"
  ]
);

// SLIDE 24: Prosthetic Valve IE
addContentSlide(pres, "Prosthetic Valve Endocarditis (PVE)", [
  "Accounts for 10-20% of all cases of IE; high mortality 20-40%",
  "EARLY PVE (<2 months post-surgery): perioperative contamination source",
  "  Organisms: Staph. epidermidis, S. aureus, gram-negatives, fungi",
  "LATE PVE (>2 months): similar to native valve IE",
  "  Organisms: viridans streptococci, S. epidermidis, Enterococcus",
  "Clinical features: fever, new murmur, signs of valve dysfunction, new AV block",
  "Diagnosis: TEE preferred over TTE for prosthetic valves (higher sensitivity)",
  "PET-CT (18F-FDG) valuable when echo inconclusive",
  "Treatment: longer IV antibiotic courses (6-8 weeks); add Rifampicin for Staphylococcal PVE",
  "Surgery often required: valve dehiscence, paravalvular leak, abscess, refractory infection"
]);

// SLIDE 25: Splinter hemorrhages image
addImageSlide(pres,
  "Splinter Hemorrhages - Peripheral Sign of IE",
  imgSplinter,
  "Splinter hemorrhages: linear dark-red subungual hemorrhages caused by microemboli",
  [
    "SPLINTER HEMORRHAGES:",
    "  Linear, dark-red, subungual hemorrhages",
    "  Run from distal to proximal under nails",
    "  Caused by microemboli to nail bed capillaries",
    "  Not specific - also in trauma, vasculitis",
    "PERIPHERAL SIGNS SUMMARY:",
    "  Osler nodes: painful fingertip nodules (immune)",
    "  Janeway lesions: painless palmar macules (embolic)",
    "  Splinter hemorrhages: subungual linear (embolic)",
    "  Roth spots: retinal hemorrhages (embolic)",
    "  Petechiae: conjunctivae / buccal mucosa"
  ],
  false
);

// SLIDE 26: Prevention
addContentSlide(pres, "Prevention of Infective Endocarditis", [
  "AHA 2021 Scientific Statement: updated guidelines for IE prevention",
  "Antibiotic prophylaxis (AP) recommended for HIGH-RISK patients undergoing INVASIVE DENTAL procedures",
  "PREFERRED REGIMEN: Amoxicillin 2g PO (adults) / 50mg/kg PO (children) 30-60 min before procedure",
  "PENICILLIN ALLERGY: Azithromycin 500mg PO or Doxycycline (new in 2021 update)",
  "CLINDAMYCIN no longer recommended: risk of Clostridioides difficile infection",
  "NON-DENTAL procedures: routine AP NOT recommended for GI/GU/respiratory procedures",
  "GENERAL MEASURES:",
  "  Strict aseptic technique for IV catheters, pacemaker insertions",
  "  Regular dental check-ups and good oral hygiene",
  "  Avoid IV drug use; use needle exchange programs",
  "  Prompt treatment of skin/soft tissue infections",
  "  Patient education about signs of IE for high-risk individuals"
]);

// SLIDE 27: Prognosis & Outcomes
addContentSlide(pres, "Prognosis & Outcomes", [
  "In-hospital mortality: 15-20%; one-year mortality: 20-30%",
  "HEART FAILURE: single most important predictor of poor outcome",
  "Embolic events occur in 20-50% of patients; ~60% have occult brain emboli on MRI",
  "POOR PROGNOSTIC FACTORS: S. aureus, fungal IE, prosthetic valve, intracardiac abscess, stroke, heart failure",
  "GOOD PROGNOSTIC FACTORS: viridans streptococcal IE, right-sided IE, no complications, early treatment",
  "Surgical outcomes: operative mortality 10-20%; 5-year survival 60-80%",
  "Recurrence rate: ~10% in treated patients; higher with ongoing IVDU",
  "Long-term follow-up: Echo at 1, 3, 6 months post-treatment",
  "Antibiotic completion is essential - premature cessation leads to relapse",
  "Ref: Braunwald's Heart Disease; Harrison's Principles of Internal Medicine 22E (2025)"
]);

// SLIDE 28: Thank You
addThankYouSlide(pres);

// Write file
pres.writeFile({ fileName: "/home/daytona/workspace/ie-ppt/Infective_Endocarditis.pptx" })
  .then(() => {
    const stats = require("fs").statSync("/home/daytona/workspace/ie-ppt/Infective_Endocarditis.pptx");
    console.log("PPT created successfully! Size:", Math.round(stats.size / 1024), "KB");
  })
  .catch(err => console.error("Error creating PPT:", err));

cd /home/daytona/workspace/ie-ppt && node build_ie_ppt_v2.js 2>&1

cd /home/daytona/workspace/ie-ppt && python3 -c " import zipfile, re with zipfil…