const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Physiotherapy in Brachytherapy for Cervical Cancer";
pres.author = "Oncology Rehabilitation Training";

// ─── COLOUR PALETTE ──────────────────────────────────────────────────────────
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  sky:     "3AB8C9",  // lighter accent
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  white:   "FFFFFF",
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  textDark:"0D2B45",
  textMid: "2C5364",
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// ─── HELPERS ─────────────────────────────────────────────────────────────────
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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════════════════
{
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  s.addText("PHYSIOTHERAPY IN", { x: 0.7, y: 0.8, w: 9, h: 0.7, fontSize: 26, bold: true, color: C.sky, fontFace: "Calibri", charSpacing: 3 });
  s.addText("BRACHYTHERAPY FOR\nCERVICAL CANCER", { x: 0.7, y: 1.45, w: 9, h: 1.7, fontSize: 42, bold: true, color: C.white, fontFace: "Calibri" });
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  s.addText("May 2026", { x: 0.7, y: 4.1, w: 4, h: 0.4, fontSize: 13, color: C.sky, fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 2 — LEARNING OBJECTIVES
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Learning Objectives");
  footerBar(s);
  const objs = [
    "Describe the principles of brachytherapy and its role in cervical cancer treatment",
    "Identify the acute and late side effects relevant to physiotherapy management",
    "Explain the physiotherapist's role during and after brachytherapy hospitalisation",
    "Apply evidence-based interventions: pelvic floor rehabilitation, dilator therapy, lymphoedema management and exercise",
    "Recognise red flags requiring urgent referral and multidisciplinary escalation",
    "Support patient education and self-management strategies post-treatment",
  ];
  bullets(s, objs, 0.5, 1.05, 9.1, 4.1, 14);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 3 — SECTION: CERVICAL CANCER & BRACHYTHERAPY OVERVIEW
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionHeader(s, "Section 1", "Cervical Cancer & Brachytherapy — Clinical Overview");
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 4 — CERVICAL CANCER EPIDEMIOLOGY & STAGING
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Cervical Cancer — Key Facts");
  footerBar(s);
  // left column: facts
  card(s, 0.35, 1.1, 4.5, 1.9,
    "Epidemiology",
    "4th most common cancer in women worldwide. HPV responsible for >99% of cases. Peak incidence 35–44 years. Squamous cell carcinoma ~75%; adenocarcinoma ~20%.",
    C.navy);
  card(s, 0.35, 3.1, 4.5, 2.1,
    "FIGO Staging (2018)",
    "Stage I: confined to cervix\nStage II: beyond cervix, not to pelvic wall\nStage III: extends to pelvic wall / lower vagina / hydronephrosis\nStage IV: bladder, rectum, or distant metastases",
    C.navy);
  // right column
  card(s, 5.15, 1.1, 4.5, 1.9,
    "Standard Treatment Approach",
    "Stage IB2–IVA: concurrent chemoradiation (cisplatin-based) + brachytherapy boost.\nSurgery for early-stage (IA–IB1): radical hysterectomy ± adjuvant radiation.",
    C.teal);
  card(s, 5.15, 3.1, 4.5, 2.1,
    "Why Brachytherapy?",
    "Delivers high-dose radiation precisely to the cervical tumour while sparing adjacent bladder and rectum.\nEssential component of curative treatment.\nCure rates: ~70% (stage I), ~60% (stage II), ~45% (stage III).",
    C.teal);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 5 — BRACHYTHERAPY PROCEDURE
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Brachytherapy — Procedure Overview");
  footerBar(s);
  const steps = [
    ["1. Applicator Insertion", "Under general/spinal anaesthesia: intrauterine tandem + vaginal ring/ovoid applicators (e.g. Vienna applicator for combined intracavitary/interstitial approach)"],
    ["2. Imaging", "MRI or CT performed with applicator in situ for 3D image-guided planning (GEC-ESTRO / ABS guidelines)"],
    ["3. Treatment Delivery", "High-dose rate (HDR) Ir-192 source delivered in 4–6 fractions over 1–2 weeks. Each fraction ~10–20 minutes"],
    ["4. Hospitalisation", "Requires strict bed rest during applicator dwell time. Patient immobilised 1–5 days depending on protocol"],
    ["5. Discharge", "Post-procedure monitoring for bleeding, infection, urinary retention. Physiotherapy role begins here"],
  ];
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    const x = 0.35 + (i % 3) * 3.1;
    const y = i < 3 ? 1.08 : 3.0;
    const w = 2.9;
    const h = 1.7;
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}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 6 — SECTION: SIDE EFFECTS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionHeader(s, "Section 2", "Side Effects Relevant to Physiotherapy");
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 7 — ACUTE VS LATE SIDE EFFECTS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Side Effects of Chemoradiation + Brachytherapy");
  footerBar(s);
  // Two-panel layout
  slide_addPanelLabel(s, "ACUTE (during/immediately post-treatment)", 0.35, 1.05, 4.45, C.teal);
  const acute = [
    "Pelvic pain & perineal discomfort",
    "Vaginal discharge / bleeding",
    "Urinary symptoms: frequency, dysuria, urgency",
    "Bowel: diarrhoea, tenesmus",
    "Fatigue & deconditioning",
    "Anxiety, psychological distress, perceived stress",
    "Reduced mobility (bed rest protocol)",
    "Thromboembolism risk (DVT/PE) from immobility",
  ];
  bullets(s, acute, 0.35, 1.6, 4.4, 3.7, 12);

  slide_addPanelLabel(s, "LATE (months to years post-treatment)", 5.15, 1.05, 4.45, C.coral);
  const late = [
    "Vaginal stenosis / fibrosis",
    "Sexual dysfunction (dyspareunia, libido changes)",
    "Pelvic floor dysfunction: urinary / bowel incontinence",
    "Lymphoedema (lower limb, genitalia)",
    "Pelvic organ prolapse",
    "Radiation enteritis / proctitis",
    "Neuropathic pain / peripheral neuropathy",
    "Radiation-induced fatigue & reduced exercise capacity",
  ];
  bullets(s, late, 5.15, 1.6, 4.4, 3.7, 12);

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}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 8 — SECTION: PHYSIOTHERAPY ROLES
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionHeader(s, "Section 3", "The Physiotherapist's Role — Assessment to Rehabilitation");
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 9 — INPATIENT PHYSIOTHERAPY (During Brachytherapy)
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Inpatient Physiotherapy — During Brachytherapy Admission");
  footerBar(s);
  card(s, 0.35, 1.1, 2.85, 4.1,
    "Respiratory & Circulatory Care",
    "• Breathing exercises (diaphragmatic, pursed-lip)\n• Ankle pumps & calf muscle activation\n• DVT prevention: compression hosiery, positional changes within bed-rest limits\n• Incentive spirometry if indicated",
    C.navy, 11);
  card(s, 3.4, 1.1, 2.85, 4.1,
    "Pain & Comfort Management",
    "• Positioning advice to minimise pelvic discomfort\n• TENS (if compatible with applicator — check with radiation team)\n• Relaxation techniques (guided breathing, progressive muscle relaxation)\n• Physiotherapy-yoga protocol (KYOCOL trial, 2025): reduces perceived stress during HDR",
    C.teal, 11);
  card(s, 6.45, 1.1, 2.85, 4.1,
    "Early Mobilisation & Education",
    "• Gradual mobilisation post-applicator removal\n• Falls prevention assessment\n• Education: expected side effects, self-management strategies\n• Pelvic floor awareness exercises (introduce concept pre-discharge)\n• Goal-setting for outpatient rehab",
    C.coral, 11);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 10 — PELVIC FLOOR REHABILITATION
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Pelvic Floor Rehabilitation");
  footerBar(s);
  // Assessment box
  card(s, 0.35, 1.08, 4.5, 2.0,
    "Assessment Tools (Evidence-Based)",
    "• PERFECT scale — pelvic floor muscle function (most used: 20.2%)\n• Female Sexual Function Index (FSFI) — sexual dysfunction (46.7%)\n• Voiding diary — urinary incontinence (45.9%)\n• Bristol Stool Scale — bowel / anal incontinence\n• Pelvic organ prolapse grading (POPQ)\n  [Moura et al., 2025 — PMID 39881620]",
    C.navy, 11);
  card(s, 0.35, 3.18, 4.5, 2.08,
    "Key Pelvic Floor Disorders Treated",
    "Sexual dysfunction (26%) | Mixed UI (24%) | Urge UI (14%)\nPelvic organ prolapse (9%) | Anal incontinence (4%)\n→ High prevalence post-chemoradiation (Miguel et al., 2020 — PMID 32530941)",
    C.coral, 11);
  card(s, 5.1, 1.08, 4.55, 2.0,
    "Intervention: Urinary Incontinence",
    "• Pelvic floor muscle training (PFMT) — first-line (32.9%)\n• Bladder training & behavioural therapy (31.7%)\n• Urge suppression techniques\n• Biofeedback / electrostimulation if PFMT alone insufficient",
    C.teal, 11);
  card(s, 5.1, 3.18, 4.55, 2.08,
    "Intervention: Anal Incontinence & Prolapse",
    "Anal incontinence: posterior tibial nerve electrostimulation (38.8%), PFMT, bowel retraining\nProlapse: PFMT (77.4%), postural advice, avoidance of Valsalva, lifestyle modification",
    C.teal, 11);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 11 — VAGINAL STENOSIS & DILATOR THERAPY
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Vaginal Stenosis & Dilator Therapy");
  footerBar(s);
  s.addText("Radiation causes vaginal fibrosis and stenosis — a major cause of dyspareunia and reduced quality of life", {
    x: 0.4, y: 1.05, w: 9.2, h: 0.55, fontSize: 13, color: C.textMid, fontFace: "Calibri", italic: true
  });
  const items = [
    ["Why it occurs", "Radiation-induced inflammation → fibrosis → progressive stenosis\nPostmenopausal patients at highest risk (reduced oestrogen)\nStenosis may impair ongoing gynaecological surveillance"],
    ["When to start", "ABS / GEC-ESTRO recommend vaginal dilator use within 4–8 weeks post-brachytherapy\nOnce acute radiation reaction has settled"],
    ["Dilator Protocol", "Insert dilator 3×/week for 10–15 min\nProgress through graded sizes\nWater-based lubricant recommended\nAlternatively: regular sexual intercourse (if appropriate and patient-centred)"],
    ["Compliance Challenges", "Pain, embarrassment, lack of education are key barriers\nEducational interventions significantly improve dilator compliance (Brand et al., 2012 — PMID 22552831)\nPhysiotherapist role: counselling, graded desensitisation (23.3%), written instructions"],
  ];
  items.forEach(([title, body], i) => {
    const col = i < 2 ? C.teal : C.navy;
    card(s, 0.35 + (i % 2) * 4.8, 1.68 + Math.floor(i / 2) * 1.95, 4.55, 1.82, title, body, col, 10.5);
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 12 — LYMPHOEDEMA MANAGEMENT
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Lower Limb Lymphoedema Management");
  footerBar(s);
  s.addText("Pelvic lymph node dissection + radiation → disruption of lymphatic drainage → lower limb / genital lymphoedema", {
    x: 0.4, y: 1.04, w: 9.2, h: 0.5, fontSize: 12, color: C.textMid, fontFace: "Calibri", italic: true
  });
  card(s, 0.35, 1.62, 3.0, 3.65,
    "Assessment",
    "• Limb volume measurement (circumference or perometry)\n• Tissue tonometry\n• Lymphoscintigraphy if available\n• Pitting vs non-pitting oedema\n• Impact on mobility, ADLs, QoL\n• Psychosocial impact",
    C.navy, 11);
  card(s, 3.55, 1.62, 3.0, 3.65,
    "CDT — Complete Decongestive Therapy",
    "Phase 1 (Intensive):\n• Manual Lymphatic Drainage (MLD)\n• Compression bandaging\n• Exercise (decongestive exercises)\n• Skin care & education\n\nPhase 2 (Maintenance):\n• Compression garments (graduated)\n• Home MLD self-drainage\n• Exercise continuation",
    C.teal, 11);
  card(s, 6.75, 1.62, 2.9, 3.65,
    "Evidence & Precautions",
    "Evidence-based review supports CDT for lower limb lymphoedema in gynaecological cancer [Iwersen et al., 2017 — PMID 27918865]\n\nPrecautions:\n• Active radiation dermatitis\n• DVT (contraindication to MLD)\n• Active infection / cellulitis\n• Cardiac / renal dysfunction",
    C.coral, 11);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 13 — EXERCISE & FATIGUE MANAGEMENT
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Exercise Therapy & Cancer-Related Fatigue");
  footerBar(s);
  card(s, 0.35, 1.08, 4.5, 2.08,
    "Cancer-Related Fatigue (CRF)",
    "Chronic fatigue affects up to 70% of cervical cancer survivors post-radiotherapy [Steen et al., 2017 — PMID 28552254]\n\nAssessment: FACIT-Fatigue scale, VAS, PSQI (sleep)\nDistinguish from anaemia, hypothyroidism, depression",
    C.navy, 11);
  card(s, 5.1, 1.08, 4.55, 2.08,
    "Return-to-Work & Function",
    "Fatigue is the leading barrier to return to work post-pelvic radiotherapy [Meixner et al., 2022 — PMID 35565459]\n\nGoal: progressive functional restoration, vocational rehabilitation planning, graded activity",
    C.teal, 11);
  card(s, 0.35, 3.25, 4.5, 2.0,
    "Exercise Prescription Principles",
    "• Aerobic exercise: 150 min/week moderate intensity (WHO)\n• Resistance training: 2×/week major muscle groups\n• Start low, go slow — adapted to functional capacity\n• Supervised exercise preferred during active treatment",
    C.teal, 11);
  card(s, 5.1, 3.25, 4.55, 2.0,
    "ACUMEN Trial (2025 — PMID 40691826)",
    "RCT protocol: structured exercise intervention to enhance treatment outcomes post-gynaecological cancer. Outcomes: QoL, fatigue, body composition, lymphoedema.\nSupports integration of exercise into standard oncology care",
    C.coral, 11);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 14 — PSYCHOLOGICAL SUPPORT & EDUCATION
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Psychological Support & Patient Education");
  footerBar(s);
  s.addText("Brachytherapy causes significant psychological distress — physiotherapy addresses both body and mind", {
    x: 0.4, y: 1.04, w: 9.2, h: 0.45, fontSize: 12, color: C.textMid, fontFace: "Calibri", italic: true
  });
  const items = [
    ["KYOCOL Protocol (2025)", "Physiotherapy-yoga + patient education programme during HDR brachytherapy. Supervised by physiotherapist. Reduces perceived stress (PSS-10) at 15 days post-treatment. Includes daily autonomous sessions during and after brachytherapy.\n[Faravel et al. — PMID 40467316]"],
    ["Patient-Reported Symptoms", "Women describe: pain, fatigue, distress, bowel/bladder concerns, sexual anxiety. Self-management strategies include: rest, positioning, social support, relaxation, information-seeking.\n[Christiansen et al., 2022 — PMID 32675630]"],
    ["Key Education Topics", "• What to expect during brachytherapy\n• DVT prevention / early mobility\n• Vaginal dilator use & rationale\n• Pelvic floor exercises\n• Lymphoedema warning signs\n• When to seek help (red flags)"],
    ["Communication Principles", "• Use plain language and check understanding\n• Address sexual health concerns sensitively\n• Involve partner/carer where appropriate\n• Provide written materials\n• Coordinate with oncology nurse, psycho-oncologist"],
  ];
  items.forEach(([title, body], i) => {
    const col = [C.navy, C.teal, C.teal, C.coral][i];
    card(s, 0.35 + (i % 2) * 4.8, 1.57 + Math.floor(i / 2) * 1.98, 4.55, 1.83, title, body, col, 10.5);
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 15 — MULTIDISCIPLINARY TEAM
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Multidisciplinary Team — Physiotherapy Integration");
  footerBar(s);
  const roles = [
    ["Radiation Oncologist", "Brachytherapy planning, dose constraints, applicator management. Physiotherapy must confirm radiation safety precautions before manual therapy", C.navy],
    ["Gynaecologic Oncologist", "Surgical staging, radical hysterectomy, pelvic exenteration. Refer for post-operative rehabilitation & lymphoedema", C.navy],
    ["Oncology Nurse", "Daily care, pain management, patient education. Key liaison for inpatient physiotherapy", C.teal],
    ["Medical Physicist", "Radiation safety. Physiotherapist must understand safe re-entry times post-HDR", C.teal],
    ["Psycho-Oncologist", "Anxiety, depression, sexual health concerns. Refer where distress is beyond physiotherapy scope", C.coral],
    ["Pelvic Health Physiotherapist", "Specialised internal examination, biofeedback. Core referral pathway for pelvic floor dysfunction", C.coral],
  ];
  roles.forEach(([title, body, col], i) => {
    card(s, 0.3 + (i % 3) * 3.15, 1.08 + Math.floor(i / 3) * 2.15, 2.95, 1.95, title, body, col, 10.5);
  });
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 16 — RED FLAGS & CONTRAINDICATIONS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Red Flags & Contraindications for Physiotherapy");
  footerBar(s);
  // Alert band
  s.addShape(pres.shapes.RECTANGLE, { x: 0.35, y: 1.08, w: 9.3, h: 0.42, fill: { color: C.coral }, line: { color: C.coral } });
  s.addText("⚠  The following require immediate escalation to the oncology team — do NOT continue physiotherapy until cleared", {
    x: 0.5, y: 1.1, w: 9.0, h: 0.38, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", valign: "middle"
  });
  const flags = [
    "Sudden severe pelvic / rectal / vaginal haemorrhage",
    "Signs of fistula (vesicovaginal / rectovaginal): faecal or urinary material per vaginum",
    "Features of DVT / pulmonary embolism (calf pain, dyspnoea, chest pain, SpO₂ drop)",
    "Acute radiation proctitis with rectal bleeding requiring intervention",
    "Bowel obstruction or perforation signs (severe abdo pain, absent bowel sounds, peritonism)",
    "Sudden neurological deficit (lower limb weakness, saddle anaesthesia) — cauda equina / cord compression",
    "Signs of sepsis (fever >38°C, tachycardia, rigors post-procedure)",
    "Bone pain suggesting skeletal metastasis or radiation-induced fracture",
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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 17 — CLINICAL PATHWAY SUMMARY
// ═══════════════════════════════════════════════════════════════════════════
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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 18 — KEY EVIDENCE SUMMARY
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    ["Chemoradiation & PFD (Miguel et al., 2020 — PMID 32530941)", "High prevalence of pelvic floor dysfunction after chemoradiation. Urinary, bowel and sexual dysfunction confirmed in survivors."],
    ["Lymphoedema CDT (Iwersen et al., 2017 — PMID 27918865)", "Evidence-based review supports CDT (MLD + compression + exercise) for lower limb lymphoedema in gynaecological cancer survivors."],
    ["Exercise Outcomes (ACUMEN Trial, 2025 — PMID 40691826)", "RCT: structured exercise post-gynaecological cancer improves QoL, fatigue, lymphoedema, body composition. Supports exercise in standard oncology care."],
    ["Dilator Compliance (Brand et al., 2012 — PMID 22552831)", "Educational intervention significantly improves vaginal dilator compliance post-radiation. Demonstrates physiotherapist's pivotal education role."],
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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 19 — SUMMARY & KEY MESSAGES
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    "Cancer-related fatigue responds to supervised exercise — prescribe progressively from low-intensity aerobic and resistance training",
    "Physiotherapy-yoga during brachytherapy (KYOCOL protocol) reduces perceived stress — non-pharmacological interventions matter",
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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 20 — REFERENCES
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    "Faravel K et al. (2025). KYOCOL — physiotherapy-yoga intervention in brachytherapy for cervical cancer. BMJ Open. PMID 40467316",
    "Moura ALC et al. (2025). Knowledge, attitude and practice of physical therapists in cervical cancer care. Physiother Theory Pract. PMID 39881620",
    "Miguel TP et al. (2020). Chemoradiation for cervical cancer portends high risk of pelvic floor dysfunction. PLoS One. PMID 32530941",
    "Christiansen MG et al. (2022). Symptom experience and self-management in cervical cancer treatment. Cancer Nurs. PMID 32675630",
    "Steen R et al. (2017). Chronic fatigue in Norwegian cervical cancer survivors. Gynecol Oncol. PMID 28552254",
    "Meixner E et al. (2022). Return to work, fatigue and cancer rehabilitation after pelvic radiotherapy. Cancers (Basel). PMID 35565459",
    "Iwersen LF et al. (2017). Evidence-based practice for lower limb lymphoedema after gynaecological cancer. Physiother Theory Pract. PMID 27918865",
    "Chiu V et al. (2025). ACUMEN — exercise trial after gynaecological cancer. BMC Cancer. PMID 40691826",
    "Brand AH et al. (2012). Educational intervention improves vaginal dilator compliance. Int J Gynecol Cancer. PMID 22552831",
    "Berek JS & Novak E. Berek & Novak's Gynecology. Primary Radiation Therapy section — brachytherapy technique and outcomes.",
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