from pptx import Presentation
from pptx.util import Inches, Pt
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.enum.shapes import MSO_SHAPE
from pptx.enum.dml import MSO_THEME_COLOR
from pptx.enum.text import MSO_AUTO_SIZE

OUT='/tmp/workspace/diabetic-foot-presentation/output/Diabetic_Foot_100_Slides.pptx'
prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5)
blank=prs.slide_layouts[6]
NAVY=RGBColor(12,40,68); TEAL=RGBColor(0,128,135); CYAN=RGBColor(77,184,190); PALE=RGBColor(239,247,247); INK=RGBColor(28,38,48); GREY=RGBColor(91,104,112); RED=RGBColor(173,50,50); WHITE=RGBColor(255,255,255); GOLD=RGBColor(217,162,46)

sections={
'INCIDENCE':(3,16),'ETIOPATHOLOGY':(17,34),'ACUTE FOOT':(35,53),'CHRONIC RECONSTRUCTION':(54,72),'DEFORMITY CORRECTION':(73,88),'PRESSURE PROFILE':(89,97),'CLOSING':(98,100)}

def add_text(slide,text,x,y,w,h,size=20,color=INK,bold=False,align=None):
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    p=tf.paragraphs[0]; p.text=text; p.alignment=align or PP_ALIGN.LEFT
    for r in p.runs: r.font.name='Aptos'; r.font.size=Pt(size); r.font.color.rgb=color; r.font.bold=bold
    return tb

def bg(slide,sec,idx):
    slide.background.fill.solid(); slide.background.fill.fore_color.rgb=WHITE
    sh=slide.shapes.add_shape(MSO_SHAPE.RECTANGLE,0,0,prs.slide_width,Inches(.28)); sh.fill.solid(); sh.fill.fore_color.rgb=NAVY; sh.line.fill.background()
    add_text(slide,sec,0.55,.36,7.5,.26,10,TEAL,True)
    add_text(slide,f'{idx:02d}',12.05,.36,.7,.26,10,GREY,True,PP_ALIGN.RIGHT)
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    add_text(slide,'Educational synthesis: supplied PDFs, Neligan Plastic Surgery 5e chapter map, IWGDF 2023 guidance',.55,7.13,11.7,.18,7,GREY)

def bullets(slide,items,x=.75,y=1.55,w=7.3,h=4.9,size=20):
    tb=slide.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h)); tf=tb.text_frame; tf.clear(); tf.word_wrap=True; tf.margin_left=Inches(.08); tf.margin_right=Inches(.04); tf.margin_top=Inches(.02); tf.margin_bottom=Inches(.02)
    for i,item in enumerate(items):
        p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.text=item; p.level=0; p.font.name='Aptos'; p.font.size=Pt(size); p.font.color.rgb=INK; p.space_after=Pt(12); p.bullet=True
    return tb

def callout(slide,title,body,x=8.55,y=1.55,w=3.9,h=3.9,color=TEAL):
    sh=slide.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(h)); sh.fill.solid(); sh.fill.fore_color.rgb=PALE; sh.line.color.rgb=color; sh.line.width=Pt(1.2)
    add_text(slide,title,x+.25,y+.22,w-.5,.42,17,color,True)
    add_text(slide,body,x+.25,y+.8,w-.5,h-1.0,15,INK)

def diagram(slide,labels,x=8.4,y=5.65,w=4.15):
    n=len(labels); bw=w/n-.08
    for i,l in enumerate(labels):
        sh=slide.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE,Inches(x+i*(bw+.08)),Inches(y),Inches(bw),Inches(.52)); sh.fill.solid(); sh.fill.fore_color.rgb=TEAL if i%2==0 else CYAN; sh.line.fill.background(); add_text(slide,l,x+i*(bw+.08)+.02,y+.10,bw-.04,.25,9,WHITE,True,PP_ALIGN.CENTER)

slides=[]
def S(title,items,call_title='',call_body='',diags=None,sec='DIABETIC FOOT'):
    slides.append((title,items,call_title,call_body,diags,sec))

# 1-100
S('Diabetic Foot: Assessment, Acute Salvage and Durable Reconstruction',['100-slide teaching presentation','Incidence, etiopathology, acute infection, skin grafting, local/free flaps, deformity correction and plantar pressure measurement','Primary source base: four supplied PDFs; supplementary framework: Neligan Plastic Surgery, 5th edition; IWGDF 2023'], 'Clinical premise','Close the wound, correct the cause, protect the reconstruction.','', 'TITLE')
S('Learning objectives',['Recognize the biological and biomechanical pathways to ulceration','Triage acute infection and identify when urgent surgery is needed','Select coverage according to defect, vascular status and loading','Plan internal offloading and quantify plantar pressure reduction'],'Six questions','What is the risk? Why did it ulcerate? Is it infected? Is it perfused? What coverage is durable? How will recurrence be prevented?',None,'TITLE')
S('Road map',['1. Incidence and burden','2. Etiopathology','3. Acute foot: cellulitis, fasciotomy and STSG','4. Chronic foot: local and free flaps','5. Deformity correction','6. Measuring the pressure profile'],'Presentation logic','The sequence follows a limb-salvage pathway: risk → diagnosis → source control → coverage → mechanical prevention.',None,'TITLE')
# incidence 4-16
S('What is diabetic foot disease?',['An ulcer, infection or destruction of deep tissues associated with diabetes and usually with neuropathy and/or peripheral arterial disease','A syndrome, not merely a wound','Management requires medical, vascular, orthopaedic/podiatric, infectious disease and reconstructive input'],'Definition','The clinically relevant unit is the entire limb: wound, perfusion, infection, mechanics and patient capacity.',None,'INCIDENCE')
S('Lifetime burden of ulceration',['Supplied Sabapathy & Periasamy review: approximately 15% lifetime ulcer risk','Other series cite risks up to 25%, reflecting population and ascertainment differences','Ulceration is commonly the initiating event before major amputation'],'Interpret cautiously','Incidence varies by case mix, access to preventive care, neuropathy prevalence and definitions.',None,'INCIDENCE')
S('Amputation burden',['Approximately 85% of diabetes-related lower-limb amputations are preceded by a foot ulcer in the supplied review','Non-traumatic lower-extremity amputation is far more common in diabetes than without diabetes','Foot preservation is a survival and mobility intervention'],'Clinical message','A healed ulcer is remission, not cure. Recurrence prevention begins on the day of closure.',None,'INCIDENCE')
S('Recurrence after healing',['First-metatarsal-head ulcer literature cited in the supplied 2022 paper: recurrence 35-40% at 3 years and about 70% by 5 years','Recurrent focal stress, rather than failure of epithelialization alone, drives many recurrences','Structured follow-up and footwear adherence are therefore treatment, not aftercare'],'High-risk phenotype','Previous ulcer, amputation, Charcot deformity, loss of protective sensation or PAD.',None,'INCIDENCE')
S('Who presents late?',['Neuropathy masks pain and permits prolonged tissue injury','Limited self-inspection, visual impairment, poor footwear, delayed referral and socioeconomic barriers contribute','In the supplied institutional series, advanced Ganga class 3/4 presentations predominated'],'Red flag','Painless deterioration should never reassure in a neuropathic foot.',None,'INCIDENCE')
S('Presentation patterns in supplied 2024 series',['Ulcer: 54%','Cellulitis: 18%','Abscess: 6%; gangrene: 14%; neuropathic ulcer: 8%','Dorsum, sole, toes and heel were all affected'],'Use of data','These are a single-center descriptive sample, not a population incidence estimate.',None,'INCIDENCE')
S('Patient factors found in supplied series',['Neuropathy 66%; ischemia 50%; osteomyelitis 18%','Trauma history 34%; mean HbA1c 9.36','Arterial Doppler frequently showed atherosclerotic change'],'Implication','Assess neuropathy, perfusion and bone involvement in every ulcer, even when infection appears superficial.',None,'INCIDENCE')
S('Risk stratification at every visit',['History: ulcer, amputation, renal disease, smoking, footwear, self-care and falls','Examination: skin, callus, deformity, pulses, Doppler where needed, loss of protective sensation','Classify risk and determine follow-up interval before the patient leaves clinic'],'Screening minimum','Inspect both feet, including interdigital spaces and plantar surfaces, with footwear removed.',None,'INCIDENCE')
S('The ulcer-amputation pathway',['Neuropathy/deformity causes repetitive pressure','Callus and occult tissue injury lead to ulcer','Ulcer permits infection; infection plus ischemia accelerates tissue loss','Failure of source control, revascularization, coverage or offloading ends in amputation'],'Break the chain','Each link is modifiable, but none should be ignored.', ['Neuropathy','Pressure','Ulcer','Infection','Amputation'],'INCIDENCE')
S('Outcome measures worth tracking',['Ulcer healing and time to healing','Major and minor amputation','Infection control, osteomyelitis remission and reoperation','Pressure reduction, recurrence, footwear adherence, ambulation and quality of life'],'Avoid narrow success','A viable flap over a recurrent ulcer-prone deformity is incomplete success.',None,'INCIDENCE')
S('Incidence: take-home points',['Diabetic foot disease is common, recurrent and limb threatening','Ulceration commonly precedes amputation','Past ulceration identifies a high-risk lifelong state','Prevention and surveillance have the same importance as reconstruction'],'Transition','Why do these ulcers form in predictable locations?',None,'INCIDENCE')
# etio 17-34
S('Etiopathology: the interacting triad',['Neuropathy','Limited joint mobility and deformity','Ischaemia','Infection frequently supervenes after skin breakdown'],'Triad from supplied review','Loss of protective sensation, high mechanical stress and impaired tissue reserve create a vulnerable foot.', ['Neuropathy','Pressure','Ischaemia'],'ETIOPATHOLOGY')
S('Sensory neuropathy',['Loss of pain, temperature and pressure perception','Minor trauma, foreign body, burns or ill-fitting footwear may not be detected','Patient continues loading despite tissue damage'],'Examination','10-g monofilament plus vibration/perception testing are screening tools; interpret in the clinical context.',None,'ETIOPATHOLOGY')
S('Motor neuropathy',['Intrinsic muscle imbalance produces clawing, prominent metatarsal heads and altered toe posture','Load shifts from broad contact areas to focal bony prominences','Plantar and dorsal shear increase with deformity and shoe conflict'],'Mechanical consequence','Structure determines where pressure will recur after the wound is closed.',None,'ETIOPATHOLOGY')
S('Autonomic neuropathy',['Reduced sweating causes dry, fissured skin','Altered vascular regulation and bone metabolism may contribute to tissue vulnerability','Fissures and interdigital maceration become portals for infection'],'Skin care','Emollients for dry skin, avoidance between toes, and early treatment of fissures.',None,'ETIOPATHOLOGY')
S('Peripheral arterial disease',['Macrovascular disease reduces healing reserve and the ability to clear infection','Calcified vessels can make ABI misleading; toe pressure, Doppler waveform and TcPO2 can add information','PAD plus infection warrants urgent vascular and surgical input'],'Do not assume','A warm foot or palpable pulse excludes neither significant PAD nor distal disease.',None,'ETIOPATHOLOGY')
S('Microvascular dysfunction and healing',['Hyperglycaemia impairs leukocyte function, collagen synthesis and wound biology','Endothelial dysfunction and capillary abnormalities reduce tissue tolerance','Correcting glucose supports but does not replace debridement, revascularization or offloading'],'Systemic preparation','Nutrition, renal status, anemia, smoking and cardiac reserve also change reconstructive risk.',None,'ETIOPATHOLOGY')
S('Advanced glycation and limited joint mobility',['Nonenzymatic glycation stiffens collagen in tendon, ligament and joint capsule','Reduced ankle and first-MTP mobility shifts pressure to forefoot and hallux','Combined with sensory loss, repetitive stress becomes clinically silent'],'Clinical clue','Equinus and restricted hallux dorsiflexion are correctable recurrence drivers.',None,'ETIOPATHOLOGY')
S('Callus is a warning sign',['Callus denotes repetitive excessive mechanical stress','The supplied review reports approximately 26% increase in focal pressure under callus','Subcallus hemorrhage or ulcer can extend deeply before detection'],'Action','Debride callus safely, then identify and reduce the force that produced it.',None,'ETIOPATHOLOGY')
S('Pressure, shear and cumulative load',['Mechanical stress reflects magnitude of plantar pressure plus loading frequency','Shear deforms tissue planes and contributes to subcallus injury','Step count, gait pattern, footwear and adherence determine cumulative exposure'],'Offloading goal','Reduce pressure at the ulcer site and reduce unprotected weight-bearing.',None,'ETIOPATHOLOGY')
S('Anatomic progression of a plantar ulcer',['Epidermal failure → dermal ulcer → fat/plantar fascia → tendon/joint/bone','Deep spaces and tendon sheaths can conduct infection proximally','Osteomyelitis and abscess must be actively sought in deep or chronic ulcers'],'Probe-to-bone','A useful clinical finding, interpreted with ulcer location, duration, infection signs and imaging.',None,'ETIOPATHOLOGY')
S('Infection biology',['Hyperglycaemia, ischemia and biofilm complicate host response','Infection is a clinical diagnosis: purulence or inflammatory signs, not culture alone','Culture guides treatment after a properly obtained tissue specimen where appropriate'],'Avoid superficial swabs','Deep tissue sampling after cleansing/debridement is more informative when infection is suspected.',None,'ETIOPATHOLOGY')
S('Charcot neuro-osteoarthropathy',['Neuropathy permits repetitive unrecognized injury and inflammation','Fragmentation, subluxation and collapse can create rocker-bottom deformity','Prominent plantar bone exposes skin to sustained high pressure'],'Key diagnostic issue','An acutely hot, swollen neuropathic foot is Charcot until convincingly excluded.',None,'ETIOPATHOLOGY')
S('Forefoot pathology: hallux and first ray',['Hallux limitus/rigidus shifts load to plantar hallux IP joint','Equinus, pronation, peroneus longus dominance and fat-pad displacement overload the first metatarsal head','Clawing magnifies toe-tip and dorsal shoe pressure'],'Map first','Measure motion, alignment, flexible versus fixed deformity, and pressure location before choosing surgery.',None,'ETIOPATHOLOGY')
S('The diabetic foot is not homogeneous',['Neuropathic foot: warm, well perfused, pressure/deformity dominant','Neuro-ischaemic foot: impaired healing reserve, often less callus, greater tissue-loss risk','Infected foot: infection severity and extent determine urgency'],'Treatment error','Applying a neuropathic reconstruction algorithm to an ischemic limb without vascular planning.',None,'ETIOPATHOLOGY')
S('Etiopathology: clinical synthesis',['Identify the cause of the wound, not only the wound','Assess sensory loss, perfusion, infection, bone, deformity and loading','Every reconstruction must be paired with a pressure-management plan'],'Transition','Acute infection requires an organized, time-critical response.',None,'ETIOPATHOLOGY')
# acute 35-53
S('Acute diabetic foot: priorities',['Recognize severity and sepsis','Resuscitate, control glucose and obtain appropriate investigations','Assess perfusion early','Drain and debride infection without delay when indicated','Plan staged coverage after source control'],'Principle','Antibiotics are adjuncts to source control when an abscess, necrosis or deep infection is present.',None,'ACUTE FOOT')
S('Cellulitis: clinical diagnosis',['Erythema, warmth, swelling, tenderness or induration; purulence may be present','Neuropathy can blunt pain; ischemia can blunt inflammatory signs','Document extent with skin marking and photograph when appropriate'],'Differentials','Charcot flare, venous disease, gout, trauma and contact dermatitis can mimic infection.',None,'ACUTE FOOT')
S('IWGDF/IDSA severity framework',['Mild: local skin/subcutaneous infection, erythema ≤2 cm, no systemic illness','Moderate: erythema ≥2 cm and/or deeper involvement, but no systemic inflammatory response','Severe: infection with systemic inflammatory response manifestations'],'Why severity matters','It directs site of care, antibiotic route, urgency of imaging and need for operative consultation.',None,'ACUTE FOOT')
S('Immediate evaluation',['Vital signs and sepsis screen','Ulcer dimensions, depth, drainage, odor, tissue viability, crepitus and fluctuance','Neurologic and vascular examination; Doppler/toe pressure where indicated','CBC, inflammatory markers, renal function, glucose; radiographs as baseline'],'Do not delay','In unstable patients or obvious deep sepsis, investigations should not postpone drainage/debridement.',None,'ACUTE FOOT')
S('Imaging in acute foot infection',['Plain radiograph: gas, foreign body, fracture, deformity and baseline bone change','Ultrasound can identify superficial collection in selected cases','MRI is useful for osteomyelitis, deep abscess, tendon/joint involvement when it will change management','CT may help define gas, complex bony anatomy or when MRI is unavailable'],'Clinical priority','Imaging complements, not replaces, surgical assessment of deep infection.',None,'ACUTE FOOT')
S('Antibiotic principles',['Obtain suitable culture specimen when feasible without delaying care','Choose empiric therapy by severity, prior cultures, local resistance, renal function and ischemia','Narrow based on tissue culture and clinical response','Address wound care, offloading, perfusion and glycaemia concurrently'],'Avoid false security','Antibiotics alone cannot reliably sterilize devitalized tissue or an undrained abscess.',None,'ACUTE FOOT')
S('Urgent surgery: guideline triggers',['Severe infection','Moderate infection with extensive gangrene, necrotizing infection, suspected deep below-fascia abscess, compartment syndrome or severe ischemia','Early surgery, generally within 24-48 hours, is considered for moderate/severe infection with necrotic tissue'],'Source','IWGDF/IDSA 2023 infection guidance.',None,'ACUTE FOOT')
S('Radical debridement',['Excise necrotic skin, fat, fascia, tendon and infected bone until viable bleeding tissue is reached','Open all involved spaces and break loculations','Obtain deep tissue/bone specimens appropriately','Preserve useful structures only when viable and compatible with infection control'],'Supplied review experience','One exhaustive debridement controlled infection in 89% of their series; repeat debridement remained necessary in selected patients.',None,'ACUTE FOOT')
S('Fasciotomy: when is it relevant?',['Routine fasciotomy is not treatment for uncomplicated cellulitis','Consider urgent fascial-space decompression when compartment syndrome, deep abscess under fascia or necrotizing infection is suspected','Incisions should permit drainage of involved compartments while protecting viable neurovascular structures'],'Important source note','The supplied PDFs emphasize radical debridement, not a diabetic-foot-specific routine fasciotomy protocol.',None,'ACUTE FOOT')
S('Recognizing compartment syndrome',['Disproportionate escalating pain may be absent in neuropathy','Tense swelling, pain with passive stretch, paresthesia, weakness and perfusion changes are warning signs','Serial examination and compartment-pressure measurement may support diagnosis when uncertainty remains'],'Clinical warning','Neuropathy makes reliance on pain particularly unsafe.',None,'ACUTE FOOT')
S('Deep plantar-space infection',['Look for plantar swelling, loss of arch contour, fluctuance, severe edema, spreading erythema and systemic toxicity','Understand tendon and fascial pathways to avoid incomplete drainage','Plan counterincisions only where necessary; avoid creating nonfunctional scars across critical weight-bearing zones'],'Operative objective','Drain pus, excise necrosis and leave a viable wound that can be reassessed.',None,'ACUTE FOOT')
S('Staged wound management after debridement',['Reassess viability and infection control serially','Use appropriate dressings; negative-pressure therapy may help selected clean, prepared wounds','Optimize perfusion and systemic state before definitive coverage','Do not close a contaminated or ischemic wound under tension'],'Decision point','A clean, vascularized, stable wound bed is the gateway to graft or flap.',None,'ACUTE FOOT')
S('STSG: suitable indications',['Well-vascularized granulating wound with no uncontrolled infection','Dorsal foot defects and non-weight-bearing plantar areas','Adjunct after toe/ray procedures when durable padding is not required','Selected patients unsuitable for lengthy flap procedures'],'Supplied 2024 series','STSG alone was the most common reconstruction, used in 58% of 50 cases.',None,'ACUTE FOOT')
S('STSG: contraindications and limitations',['Exposed avascular tendon, bone or hardware without vascularized bed','Active infection, necrosis, uncontrolled edema or inadequate perfusion','High-shear/high-pressure plantar surface without a durable offloading strategy','Inability to protect graft postoperatively'],'Core limitation','A graft replaces skin, not cushioning, vascular bulk or biomechanics.',None,'ACUTE FOOT')
S('STSG operative sequence',['Debride and ensure hemostasis without hematoma','Prepare a clean, stable recipient bed','Harvest thin split-thickness graft; mesh or sheet according to defect and contour','Secure graft, apply nonadherent interface and bolster/immobilize','Elevate and protect from shear'],'Postoperative care from supplied series','First dressing at 48 hours, then at 72-hour intervals; elevation and immobilization were used.',None,'ACUTE FOOT')
S('STSG complications and prevention',['Hematoma/seroma: meticulous hemostasis and contact','Infection: source control, appropriate antimicrobial therapy, surveillance','Shear: splintage, offloading, patient education','Partial loss: reassess perfusion, infection and mechanical exposure before regrafting'],'Supplied series outcome','Partial graft loss 16%; total graft loss 2%, with repeat grafting used when necessary.',None,'ACUTE FOOT')
S('Acute foot: exit criteria before definitive reconstruction',['No progressive necrosis or purulence','Viable wound bed and controlled edema','Adequate perfusion or a revascularization plan','Glycaemia and comorbidities optimized as feasible','Clear plan for pressure relief, protection and follow-up'],'Transition','The chronic defect is reconstructed according to anatomy, loading and vascular options.',None,'ACUTE FOOT')
# chronic 54-72
S('Chronic reconstruction: reconstructive ladder',['Secondary healing or advanced dressings for selected minor wounds','STSG for superficial vascularized, low-load defects','Local/regional flap for small to medium defects needing padding','Free tissue transfer for large, deep, complex or poorly served defects'],'Rule','Choose the least complex option that yields stable, durable coverage and permits function.',None,'CHRONIC RECONSTRUCTION')
S('Reconstructive assessment',['Defect: site, size, depth, exposed structures, contamination and dead space','Limb: pulses, imaging, revascularization options, edema and infection','Patient: renal/cardiac reserve, nutrition, glycaemia, anticoagulation, adherence and goals','Biomechanics: weight-bearing surface, deformity, pressure map and footwear'],'Decision matrix','A technically possible flap is inappropriate if the limb cannot be perfused or protected.',None,'CHRONIC RECONSTRUCTION')
S('Local flaps: advantages and limits',['Like-with-like tissue match, short operation and no microsurgery','Often thicker and more durable than grafts','Useful for small to medium defects with reliable adjacent skin and blood supply','Restricted by local tissue scarcity, scarring, infection and diabetic arterial disease'],'Use thoughtfully','Do not undermine or rotate compromised tissue into a pressure zone.',None,'CHRONIC RECONSTRUCTION')
S('Local advancement flaps',['Advance adjacent lax tissue into small defects','Useful after excision/debridement when tension is low and perfusion is reliable','Design to avoid placing a suture line directly over a peak pressure point','May be combined with grafting of donor/raw area'],'Supplied series','Local advancement flaps were used in 4% of patients.',None,'CHRONIC RECONSTRUCTION')
S('Rotation and transposition flaps',['Redistribute nearby tissue around a pivot point','Can provide better reach than straight advancement','Require a broad, well-perfused base and careful tension control','Assess donor site closure and potential for secondary pressure problems'],'Supplied series','Rotation-advancement and transposition flaps were each used in selected cases.',None,'CHRONIC RECONSTRUCTION')
S('Toe fillet flaps',['Use viable soft tissue from a non-salvageable toe to cover adjacent defect','Particularly useful after toe/ray amputation with exposed metatarsal or soft-tissue deficit','Preserve vascular pedicle and avoid tension/kinking','May be paired with STSG for residual raw area'],'Advantages','Uses local sensate, durable tissue without a distant donor site.',None,'CHRONIC RECONSTRUCTION')
S('Medial plantar artery flap',['Provides glabrous, durable, potentially sensate plantar-like skin','Useful for heel and selected plantar weight-bearing defects','Requires intact donor-site vascularity and careful protection of medial plantar neurovascular structures','Donor site generally requires grafting'],'Supplied series','Medial plantar artery flaps were used in 6% of cases.',None,'CHRONIC RECONSTRUCTION')
S('Heel reconstruction principles',['Heel requires durable tissue that tolerates shear and repetitive load','Assess calcaneal osteomyelitis, Achilles function, posterior tibial/plantar circulation and hindfoot alignment','Glabrous plantar tissue is ideal where feasible; free flap may be necessary for extensive loss','Long-term heel offloading and footwear modification are mandatory'],'Do not neglect mechanics','Calcaneal gait from Achilles insufficiency can perpetuate heel ulceration.',None,'CHRONIC RECONSTRUCTION')
S('Regional flap options',['Reverse sural, perforator-based and muscle flaps may be considered by defect location and vascular anatomy','They offer alternatives when free tissue transfer is unavailable or excessive','Venous congestion, arterial disease and infection can limit reliability','Choose with Doppler/angiographic understanding of inflow and outflow'],'Context','Specific flap choice must match local expertise and patient anatomy.',None,'CHRONIC RECONSTRUCTION')
S('When to choose a free flap',['Large defect, exposed bone/tendon/joint, dead space, or failed local coverage','Need for vascularized bulk after radical debridement','When local tissue is inadequate but recipient vessels and patient reserve are acceptable','A planned staged pathway is often safer after severe infection'],'Free flap is not rescue alone','It should be part of a complete perfusion, infection and biomechanics plan.',None,'CHRONIC RECONSTRUCTION')
S('ALT free flap',['Large skin paddle, long pedicle and option for fasciocutaneous or muscle-inclusive tissue','Suitable for extensive dorsal, ankle or complex foot defects','Can be thinned selectively, but avoid jeopardizing perfusion','Donor morbidity is generally acceptable but must be discussed'],'Supplied series','ALT was the most frequently reported free flap, used in 10% of cases; all reported total/partial flap losses occurred in ALT cases.',None,'CHRONIC RECONSTRUCTION')
S('Gracilis free flap',['Reliable vascularized muscle for irregular cavities and postinfective defects','May be covered with STSG','Useful when thin, conforming vascularized tissue is required','Muscle atrophy over time can be beneficial for contour but may reduce cushioning'],'Supplied review figures','Gracilis was illustrated for postinfective central-ray loss and extensive heel soft-tissue loss.',None,'CHRONIC RECONSTRUCTION')
S('Radial forearm free flap',['Thin pliable fasciocutaneous tissue for selected contour-sensitive defects','Requires assessment of donor hand circulation and donor-site planning','Not designed to create a primary weight-bearing plantar cushion','Use where thin coverage and reliable pedicle characteristics are appropriate'],'Supplied series','Radial forearm free flaps were used in 4% of patients.',None,'CHRONIC RECONSTRUCTION')
S('Recipient vessels and vascular planning',['Assess arterial inflow and venous outflow before free tissue transfer','Avoid anastomosis within infected or severely diseased field where possible','Coordinate revascularization and reconstruction with vascular surgery','Plan recipient vessels before flap harvest when risk is high'],'Timing','In selected infected limbs, staged debridement and vessel identification before definitive flap is prudent.',None,'CHRONIC RECONSTRUCTION')
S('Free-flap operative and monitoring principles',['Two-team approach can shorten operative time','Meticulous debridement and recipient-site preparation are decisive','Postoperative monitoring includes clinical color, temperature, capillary refill, turgor and Doppler signal','Maintain systemic perfusion, warmth, elevation and avoid compression/kinking'],'Supplied protocol','Hourly monitoring first 24 h, then decreasing frequency, was described in the 2024 series.',None,'CHRONIC RECONSTRUCTION')
S('Flap failure: causes and response',['Arterial thrombosis, venous congestion, hematoma, infection, vasospasm and systemic hypoperfusion','Recognize changing color, temperature, turgor or Doppler signal immediately','Return to theatre early when salvage is plausible','After failure, reassess infection, perfusion, thrombosis risk and reconstructive goal'],'Evidence update','A 2024 systematic review/meta-analysis on flap reconstruction for diabetic foot ulcers is available (PMID 38334716).',None,'CHRONIC RECONSTRUCTION')
S('Coverage does not equal cure',['Even padded flaps can ulcerate when placed over persistent deformity','Plan tendon balancing, bone work, offloading, orthoses and footwear before or with reconstruction','Teach daily inspection of flap/graft margins and pressure areas','Establish rapid access for callus or pre-ulcer care'],'Reconstructive endpoint','Stable, shoeable, surveilled foot with minimized focal load.',None,'CHRONIC RECONSTRUCTION')
S('Chronic reconstruction: selection summary',['Dorsal superficial: STSG often suitable after bed preparation','Plantar/heel small-medium: local glabrous or regional tissue if vascularity permits','Large/deep or exposed structures: free flap after infection/perfusion control','Any location: correct the pressure generator and protect long term'],'Transition','Surgical offloading turns wound coverage into durable limb preservation.',None,'CHRONIC RECONSTRUCTION')
# deform 73-88
S('Deformity correction: objectives',['Remove focal bony prominence or reduce pathological force','Restore plantigrade alignment and improve shoe accommodation','Increase ankle dorsiflexion when equinus overloads forefoot','Prevent recurrence and transfer lesions'],'Principle','Operate on a demonstrated deforming force, not simply on an ulcer location.',None,'DEFORMITY CORRECTION')
S('Preoperative biomechanical work-up',['Standing and gait assessment','Skin/callus map and ulcer history','Passive and active ankle, MTP and IP motion','Weight-bearing radiographs; MRI/CT as indicated','Pedobarography where available'],'Document baseline','The operation should have an explicit, testable pressure-reduction hypothesis.',None,'DEFORMITY CORRECTION')
S('Silfverskiöld test and equinus',['Dorsiflexion limited with knee extended but improves with flexion: gastrocnemius contracture','Limited with knee both extended and flexed: gastrocnemius-soleus/Achilles contracture','Equinus increases forefoot loading and can perpetuate metatarsal-head ulceration'],'Surgical options','Gastrocnemius recession or Achilles tendon lengthening selected according to the contracture pattern and patient risk.',None,'DEFORMITY CORRECTION')
S('Achilles lengthening: benefits and risks',['Can reduce forefoot pressure in selected equinus-associated ulcers','Avoid overlengthening, calcaneal gait and heel transfer ulceration','Protect with staged return to weight-bearing and pressure surveillance','Reassess gait and heel loading after surgery'],'Supplied 2022 cohort','Percutaneous Achilles lengthening was part of the tailored first-metatarsal-head offloading protocol.',None,'DEFORMITY CORRECTION')
S('Hallux limitus and plantar hallux IP ulcer',['Restricted first-MTP dorsiflexion transfers pressure to the hallux IP plantar surface','Assess functional hallux limitus with Hubscher maneuver','Early flexible cases may be addressed with selective plantar fascia release','Recalcitrant hallux rigidus-associated ulcer may require Keller excision arthroplasty in selected patients'],'Technical caution','Balance ulcer healing, toe stability and push-off function.',None,'DEFORMITY CORRECTION')
S('Toe-tip ulcers and flexor tenotomy',['Mallet toe: distal interphalangeal flexion causes toe-tip overload','Flexible deformity with tip ulcer can respond to percutaneous/open flexor tenotomy','Claw toe may require more extensive tendon balancing or arthrodesis if fixed','Screen for osteomyelitis in a swollen “sausage” toe'],'Goal','Remove distal pressure while preserving a shoeable, stable toe.',None,'DEFORMITY CORRECTION')
S('Claw toe correction',['Claw toe combines MTP hyperextension with PIP/DIP flexion','Flexible deformity: tendon transfer such as Girdlestone-Taylor plus extensor lengthening may be considered','Fixed deformity: neutral-position arthrodesis may be required','Avoid creating new dorsal shoe pressure or adjacent toe conflict'],'Follow-up','Monitor for transfer lesions, especially after changing forefoot contact pattern.',None,'DEFORMITY CORRECTION')
S('First metatarsal head overload',['Contributors: equinus, plantar-flexed first ray, pronation, sesamoid pathology, hallux clawing and fat-pad displacement','Preserve the first ray where possible because it is important for gait','Options must be tailored: tendon balancing, sesamoidectomy, osteotomy, joint stabilization and fat padding in selected cases'],'Supplied 2022 protocol','Used a multi-factor assessment with pedobarography, radiographs, MRI and gait analysis.',None,'DEFORMITY CORRECTION')
S('Peroneus longus to brevis transfer',['Peroneus longus can plantarflex the first ray and contribute to first-metatarsal-head overload','Transfer/lengthening redirects force and may reduce plantar first-ray pressure','Consider only after confirming deformity pattern and evaluating lateral-column stability','Combine with other corrections where multiple forces coexist'],'Avoid isolated thinking','Most recurrent ulcers have more than one mechanical driver.',None,'DEFORMITY CORRECTION')
S('Metatarsal head procedures',['Metatarsal head resection can remove a focal prominence in selected lesser-ray ulcers','Risk: transfer ulcer under adjacent metatarsals and altered propulsion','Pan-metatarsal head resection is a salvage option for multiple/recurrent transfer lesions','Dorsal approach may reduce plantar scar burden'],'Selection','Balance bone infection, pressure distribution, vascular status and functional goals.',None,'DEFORMITY CORRECTION')
S('Jones transfer and first-ray balance',['Jones transfer transfers EHL to first metatarsal with great-toe IP fusion in selected clawed hallux/first-ray patterns','Can correct clawing and redistribute first-ray mechanics','Requires appropriate soft tissue, bone quality and postoperative protection','Not a substitute for addressing equinus or pronation when present'],'Surgical planning','Combine procedures only when each has a defined biomechanical purpose.',None,'DEFORMITY CORRECTION')
S('Supination and lateral column ulcer',['Cavus/supinated foot overloads fifth metatarsal and lateral border','Split tibialis anterior tendon transfer to lateral foot may address dynamic varus/supination in selected feet','Assess hindfoot flexibility and muscle balance','Use footwear/orthotic modifications even after tendon transfer'],'Measure outcome','Track lateral plantar pressure, callus and shoe wear pattern.',None,'DEFORMITY CORRECTION')
S('Charcot staging: Eichenholtz concept',['Stage 1 fragmentation: hot swollen foot, fragmentation/dislocation','Stage 2 coalescence: inflammation subsides, early healing','Stage 3 reconstruction/consolidation: stable deformity or nonunion remains','Treatment depends on activity, ulceration, stability, bone stock and patient capacity'],'Time matters','Do not electively reconstruct an uncontrolled acute inflammatory Charcot process without a specialized plan.',None,'DEFORMITY CORRECTION')
S('Charcot ulcer and exostectomy',['A consolidated rocker-bottom prominence can cause recurrent plantar ulceration','Exostectomy may remove a discrete prominence when the foot is otherwise stable and braceable','Unstable severe deformity may require realignment arthrodesis','Soft-tissue coverage and infection status must be addressed first'],'Postoperative protection','Custom footwear, CROW/AFO and prolonged surveillance are central to success.',None,'DEFORMITY CORRECTION')
S('Arthrodesis and external fixation',['Severe instability may require fusion to restore a plantigrade foot','Poor Charcot bone can challenge internal fixation; external fixation can provide multiplanar correction/compression','Pin-tract infection and wire breakage require active surveillance','Construct selection should respect bone quality, infection and soft-tissue envelope'],'Long-term care','The supplied review recommends protective bracing for at least 12 months after reconstruction; some need lifelong protection.',None,'DEFORMITY CORRECTION')
S('Deformity correction: safeguards',['Rule out or treat ischemia and infection before elective corrective surgery','Prevent transfer lesions with post-op pressure assessment','Use staged weight-bearing and protective footwear','Set realistic expectations: recurrence risk remains lifelong'],'Transition','Pressure measurement converts biomechanical assumptions into objective data.',None,'DEFORMITY CORRECTION')
# pressure 89-97
S('Why measure plantar pressure?',['Identify focal high-load regions associated with callus/ulcer risk','Guide custom footwear, insoles, orthoses and surgical-offloading planning','Document whether a reconstruction reduced pathological load','Detect transfer loading after metatarsal or tendon procedures'],'Mechanics','Pressure magnitude alone is insufficient: duration and number of loading cycles matter.',None,'PRESSURE PROFILE')
S('Pedobarography systems',['Platform systems: barefoot dynamic walking over pressure mat','In-shoe systems: pressure within therapeutic footwear during real-world gait','Static studies describe standing distribution; dynamic studies better represent repetitive walking load','Select a validated, calibrated system with appropriate sensor spatial resolution'],'Clinical preference','In-shoe measurement is particularly relevant when optimizing therapeutic footwear.',None,'PRESSURE PROFILE')
S('Core pressure variables',['Peak plantar pressure: maximum pressure in a defined region','Pressure-time integral: cumulative pressure exposure over stance','Contact area and contact time: distribution and duration of load','Center-of-pressure path: gait progression and asymmetry'],'Interpret together','A lower peak with prolonged contact may not mean a lower cumulative mechanical burden.',None,'PRESSURE PROFILE')
S('How to acquire a pressure profile',['Inspect and clean feet; document callus/ulcer/orthosis and current footwear','Calibrate equipment and define regional mask/template','Use familiar walking speed and sufficient valid trials','Capture barefoot and, when relevant, in-shoe conditions','Record symptoms, assistive device, ulcer protection and activity restrictions'],'Safety','Do not test an unprotected infected or unstable ulcer in a manner that increases harm.',None,'PRESSURE PROFILE')
S('Regional masking and reporting',['Mask heel, midfoot, metatarsal heads, hallux and lesser toes consistently','For ulcers, create a clinically relevant region around the prior/active lesion','Report mean and variability across trials, not a single maximum','Compare side-to-side and pre/post intervention within standardized conditions'],'Traceability','Save raw maps, mask definitions, footwear configuration and patient gait conditions.',None,'PRESSURE PROFILE')
S('Interpreting the map',['High forefoot pressure: consider equinus, plantar-flexed ray, metatarsal prominence or toe deformity','Hallux IP pressure: consider hallux limitus/rigidus or flexor imbalance','Lateral overload: consider cavus/supination/varus','Heel overload: consider calcaneal gait, Achilles insufficiency or immobilization pattern'],'Maps prompt examination','Pedobarography supports, but does not replace, clinical biomechanical assessment.',None,'PRESSURE PROFILE')
S('Pressure-guided footwear optimization',['Modify rocker sole, insole contour, metatarsal bar/pad, aperture, filler or custom total-contact insert','Retest in-shoe pressures after each meaningful modification','Ensure therapeutic footwear is worn consistently, including at home','Inspect skin and insole wear at follow-up'],'IWGDF 2023 target','For high-risk sites, aim for ≥30% in-shoe peak-pressure reduction or peak pressure <200 kPa with a validated calibrated system using approximately 2 cm² sensors.',None,'PRESSURE PROFILE')
S('Evidence from supplied internal-offloading cohort',['Pedobarography measured peak plantar pressure and pressure-time integral beneath the ball of the great toe','Testing was performed preoperatively and at 12 and 18 months','Mean reduction in peak pressure/pressure-time integral reported: 79.5%','Late recurrence: 1 of 51 patients, in a selected non-ischaemic cohort'],'Interpretation','This supports tailored internal offloading but is not a universal protocol for all diabetic foot ulcers.',None,'PRESSURE PROFILE')
S('Pressure profile: common errors',['Testing too few steps or mixing walking speeds','Comparing different shoes/insoles without documentation','Ignoring sensor calibration, mask placement and trial variability','Treating a numerical reduction as success if skin, perfusion or adherence are poor','Failing to assess transfer pressure after correction'],'Final rule','Pressure should be measured, reduced and rechecked after any intervention that changes gait or foot structure.',None,'PRESSURE PROFILE')
# close 98-100
S('Integrated limb-salvage algorithm',['1. Assess severity, systemic status and perfusion','2. Control infection with antibiotics plus drainage/debridement when indicated','3. Establish a viable wound bed and revascularize where needed','4. Select durable coverage based on depth and load','5. Correct deformity and verify offloading','6. Maintain lifelong surveillance'],'Team care','The plan is only as strong as its follow-up pathway.', ['Assess','Debride','Perfuse','Cover','Offload','Surveil'],'CLOSING')
S('Key take-home messages',['Diabetic foot ulceration results from interacting neuropathy, ischemia, infection and mechanics','Cellulitis can conceal deep infection; urgent surgery is required for necrosis, deep abscess, compartment syndrome or severe ischemia','STSG is useful for prepared low-load defects; plantar/complex defects often require durable vascularized coverage','Flap success requires deformity correction and offloading','Pedobarography makes pressure reduction measurable'],'Clinical caution','This deck is educational. Individual surgical decisions require multidisciplinary assessment and local protocols.',None,'CLOSING')
S('Selected sources',['Supplied PDFs: Sabapathy & Periasamy, IJPS 2016; Balakrishnan et al., IJPS 2022; Ghelani et al., 2024; Varma, IJPS 2011','Neligan et al., Plastic Surgery, 5th ed., Volume 9: diabetic foot introduction, wounds/biomechanics/amputations and reconstruction chapters','IWGDF 2023 Practical, Prevention, Offloading, Infection and PAD Guidelines','IWGDF/IDSA 2023 diabetic foot infection guideline; Reed et al. flap reconstruction systematic review/meta-analysis, PMID 38334716'],'Thank you','Questions and case discussion')

assert len(slides)==100, len(slides)
for idx,(title,items,ct,cb,dg,sec) in enumerate(slides,1):
    slide=prs.slides.add_slide(blank)
    if sec=='TITLE':
        slide.background.fill.solid(); slide.background.fill.fore_color.rgb=NAVY
        # subtle panels
        s=slide.shapes.add_shape(MSO_SHAPE.RECTANGLE,Inches(8.7),0,Inches(4.65),prs.slide_height); s.fill.solid(); s.fill.fore_color.rgb=TEAL; s.line.fill.background()
        add_text(slide,title,0.75,1.05,7.4,1.5,34,WHITE,True)
        bullets(slide,items,.82,3.05,7.2,2.6,18)
        for sh in slide.shapes:
            if hasattr(sh,'text_frame') and sh.text_frame:
                for p in sh.text_frame.paragraphs:
                    for r in p.runs: r.font.color.rgb=WHITE
        add_text(slide,'DIABETIC FOOT',9.2,1.2,3.4,.6,24,WHITE,True,PP_ALIGN.CENTER)
        add_text(slide,'100-slide educational deck\nAcute salvage to durable prevention',9.15,2.25,3.4,1.2,18,WHITE,False,PP_ALIGN.CENTER)
        add_text(slide,'Source base: supplied PDFs + Neligan Plastic Surgery 5e\nGuideline framework: IWGDF 2023',.8,6.8,7.5,.3,9,RGBColor(190,215,222))
    else:
        bg(slide,sec,idx); add_text(slide,title,.7,.77,11.8,.6,27,NAVY,True); bullets(slide,items,.78,1.55,7.25,5.15,18 if len(items)<=4 else 16)
        if ct: callout(slide,ct,cb)
        if dg: diagram(slide,dg)
prs.core_properties.title='Diabetic Foot: 100-slide teaching presentation'
prs.core_properties.subject='Diabetic foot reconstruction, offloading and plantar pressure'
prs.core_properties.author='Orris'
prs.save(OUT)
print(OUT, len(prs.slides))