Tuberculosis - Comprehensive Overview

from pptx import Presentation
from pptx.util import Inches, Pt, Emu
from pptx.dml.color import RGBColor
from pptx.enum.text import PP_ALIGN, MSO_ANCHOR
from pptx.util import Inches, Pt
from io import BytesIO
import copy

prs = Presentation()
prs.slide_width = Inches(13.333)
prs.slide_height = Inches(7.5)

blank = prs.slide_layouts[6]

# ── Colour palette ─────────────────────────────────────────────────────────
C_DARK_BLUE  = RGBColor(0x1A, 0x37, 0x6C)   # dark navy
C_MED_BLUE   = RGBColor(0x1E, 0x6F, 0xB4)   # mid blue
C_ACCENT     = RGBColor(0xE8, 0x4A, 0x4A)   # red accent
C_LIGHT_BG   = RGBColor(0xF0, 0xF4, 0xFA)   # very light blue-grey
C_WHITE      = RGBColor(0xFF, 0xFF, 0xFF)
C_TEXT_DARK  = RGBColor(0x1C, 0x1C, 0x1C)
C_GOLD       = RGBColor(0xF5, 0xA6, 0x23)
C_GREEN      = RGBColor(0x1A, 0x7A, 0x3C)
C_ORANGE     = RGBColor(0xD9, 0x65, 0x00)
C_SUBHEAD    = RGBColor(0x1E, 0x6F, 0xB4)

# ── Helpers ─────────────────────────────────────────────────────────────────
def add_rect(slide, x, y, w, h, fill_color, transparency=0):
    shape = slide.shapes.add_shape(
        1,  # MSO_SHAPE_TYPE.RECTANGLE
        Inches(x), Inches(y), Inches(w), Inches(h)
    )
    shape.fill.solid()
    shape.fill.fore_color.rgb = fill_color
    shape.line.fill.background()
    return shape

def add_text(slide, text, x, y, w, h, font_size=18, bold=False,
             color=C_TEXT_DARK, align=PP_ALIGN.LEFT, italic=False,
             wrap=True, v_anchor=MSO_ANCHOR.TOP):
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = wrap
    tf.vertical_anchor = v_anchor
    tf.margin_left = Pt(0)
    tf.margin_right = Pt(0)
    tf.margin_top = Pt(2)
    tf.margin_bottom = Pt(2)
    p = tf.paragraphs[0]
    p.alignment = align
    run = p.add_run()
    run.text = text
    run.font.size = Pt(font_size)
    run.font.bold = bold
    run.font.italic = italic
    run.font.color.rgb = color
    run.font.name = "Calibri"
    return tf

def add_multiline(slide, lines, x, y, w, h, font_size=14,
                  color=C_TEXT_DARK, bold_first=False, line_spacing=1.2,
                  bullet=True):
    """lines: list of strings; bold_first makes first run bold in each line"""
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.margin_left = Pt(4)
    tf.margin_right = Pt(4)
    tf.margin_top = Pt(2)
    tf.margin_bottom = Pt(2)
    from pptx.oxml.ns import qn
    from lxml import etree
    first = True
    for i, line in enumerate(lines):
        if first:
            p = tf.paragraphs[0]
            first = False
        else:
            p = tf.add_paragraph()
        if bullet:
            p.space_before = Pt(2)
        run = p.add_run()
        if isinstance(line, tuple):
            run.text = line[0]
            run.font.bold = True
            run.font.color.rgb = line[1] if len(line) > 1 else color
            if len(line) > 2:
                run2 = p.add_run()
                run2.text = line[2]
                run2.font.bold = False
                run2.font.color.rgb = color
                run2.font.size = Pt(font_size)
                run2.font.name = "Calibri"
        else:
            run.text = ("• " if bullet else "") + line
            run.font.bold = False
            run.font.color.rgb = color
        run.font.size = Pt(font_size)
        run.font.name = "Calibri"
    return tf

def slide_header(slide, title, subtitle=None):
    """Top banner with title"""
    add_rect(slide, 0, 0, 13.333, 1.1, C_DARK_BLUE)
    add_text(slide, title, 0.25, 0.05, 12, 0.75,
             font_size=30, bold=True, color=C_WHITE, align=PP_ALIGN.LEFT)
    if subtitle:
        add_text(slide, subtitle, 0.25, 0.78, 12, 0.35,
                 font_size=13, bold=False, color=C_GOLD, align=PP_ALIGN.LEFT)
    # bottom accent line
    add_rect(slide, 0, 1.1, 13.333, 0.06, C_ACCENT)

def section_box(slide, title, x, y, w, h, content_lines, font_size=12,
                title_color=C_WHITE, box_color=C_MED_BLUE, text_color=C_TEXT_DARK,
                bg_color=C_LIGHT_BG):
    """A titled box with bullet content"""
    add_rect(slide, x, y, w, 0.38, box_color)
    add_text(slide, title, x+0.08, y+0.02, w-0.1, 0.35,
             font_size=13, bold=True, color=title_color, v_anchor=MSO_ANCHOR.MIDDLE)
    add_rect(slide, x, y+0.38, w, h-0.38, bg_color)
    add_multiline(slide, content_lines, x+0.08, y+0.42, w-0.16, h-0.5,
                  font_size=font_size, color=text_color)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 1 — Title slide
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_DARK_BLUE)
add_rect(s, 0, 5.8, 13.333, 1.7, C_MED_BLUE)
add_rect(s, 0, 3.3, 13.333, 0.08, C_ACCENT)
add_rect(s, 0, 5.72, 13.333, 0.08, C_GOLD)

add_text(s, "TUBERCULOSIS", 0.5, 0.8, 12.5, 1.5,
         font_size=60, bold=True, color=C_WHITE, align=PP_ALIGN.CENTER)
add_text(s, "Comprehensive Review", 0.5, 2.3, 12.5, 0.8,
         font_size=28, bold=False, color=C_GOLD, align=PP_ALIGN.CENTER, italic=True)
add_text(s, "Pathogenesis • Diagnosis • Management", 0.5, 3.0, 12.5, 0.5,
         font_size=18, bold=False, color=RGBColor(0xAA, 0xCC, 0xFF), align=PP_ALIGN.CENTER)
add_text(s, "Based on Harrison's Principles of Internal Medicine 22E (2025)", 0.5, 3.55, 12.5, 0.4,
         font_size=13, bold=False, color=C_GOLD, align=PP_ALIGN.CENTER, italic=True)
add_text(s, "India Management: NTEP / Central TB Division Guidelines 2025", 0.5, 4.0, 12.5, 0.4,
         font_size=13, bold=False, color=RGBColor(0xAA, 0xCC, 0xFF), align=PP_ALIGN.CENTER)
add_text(s, "National Tuberculosis Elimination Programme  |  MoHFW, Government of India",
         0.5, 6.1, 12.5, 0.4,
         font_size=12, bold=False, color=C_WHITE, align=PP_ALIGN.CENTER)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 2 — Overview & Epidemiology
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Overview & Epidemiology", "Harrison's 22E Ch. 183 | WHO Global TB Report 2024")

add_rect(s, 0.25, 1.3, 8.2, 2.5, C_LIGHT_BG)
add_rect(s, 0.25, 1.3, 8.2, 0.38, C_DARK_BLUE)
add_text(s, "Global Burden", 0.35, 1.32, 8, 0.35, font_size=13, bold=True, color=C_WHITE)
add_multiline(s, [
    "Caused by Mycobacterium tuberculosis complex",
    "~10.8 million new cases globally in 2023",
    "Returned as #1 infectious disease killer after COVID-19 (2023)",
    "M. tuberculosis emerged ~70,000 years ago in Africa",
    "Affects lungs primarily; extrapulmonary in up to 1/3 of cases",
    "If untreated: fatal in >70% of cases"
], 0.33, 1.72, 8.05, 2.0, font_size=12.5, text_color=C_TEXT_DARK)

add_rect(s, 0.25, 3.95, 8.2, 2.45, C_LIGHT_BG)
add_rect(s, 0.25, 3.95, 8.2, 0.38, C_MED_BLUE)
add_text(s, "India's TB Burden (NTEP)", 0.35, 3.97, 8, 0.35, font_size=13, bold=True, color=C_WHITE)
add_multiline(s, [
    "India accounts for ~26% of global TB burden (highest of any country)",
    "National Strategic Plan 2020-2025: Target TB-free India by 2025 (5 yrs ahead of SDG 2030)",
    "PM TB Mukt Bharat Abhiyaan: District-level elimination drive",
    "NTEP (replaced RNTCP): daily regimen, universal DST, mandatory notification",
    "~87% treatment success rate in DS-TB (2023)"
], 0.33, 4.37, 8.05, 1.9, font_size=12.5, text_color=C_TEXT_DARK)

# Right: key numbers panel
add_rect(s, 8.7, 1.3, 4.35, 5.1, C_DARK_BLUE)
for val, label, yy in [
    ("10.8M", "New cases / year", 1.45),
    ("1.25M", "Deaths / year", 2.5),
    ("26%", "Global burden\nin India", 3.55),
    ("87%", "India treatment\nsuccess rate", 4.7),
]:
    add_text(s, val, 8.85, yy, 4.0, 0.55,
             font_size=28, bold=True, color=C_GOLD, align=PP_ALIGN.CENTER)
    add_text(s, label, 8.85, yy+0.52, 4.0, 0.45,
             font_size=11, bold=False, color=C_WHITE, align=PP_ALIGN.CENTER)

add_text(s, "Source: Harrison's 22E | WHO 2024 | NTEP Annual Report 2023",
         0.25, 6.6, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 3 — Etiologic Agent
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Etiologic Agent", "M. tuberculosis complex — morphology & characteristics")

section_box(s, "M. tuberculosis Complex — Members", 0.25, 1.28, 6.1, 3.6, [
    "M. tuberculosis — principal human pathogen",
    "M. africanum — West/Central/East Africa",
    "M. bovis — zoonotic; resistant to PZA; unpasteurized milk",
    "M. caprae — related to M. bovis",
    "M. canetti — rare; East Africa; unusual smooth colonies",
    "M. microti — 'vole bacillus'; less virulent",
    "No known environmental reservoir"
], font_size=12.5)

section_box(s, "Bacteriological Properties", 6.6, 1.28, 6.45, 3.6, [
    "Rod-shaped, non-spore-forming, thin AEROBE (0.5 × 3 μm)",
    "Neutral on Gram stain → classified as ACID-FAST BACILLI (AFB)",
    "Acid-fastness: HIGH mycolic acid content in cell wall",
    "Cannot be decolorized by acid-alcohol (Ziehl-Neelsen stain)",
    "Very slow doubling time (~15-20 hours)",
    "Thick waxy cell wall → resists disinfectants & complement",
    "Other AFB: Nocardia, Rhodococcus, Legionella micdadei"
], font_size=12.5)

section_box(s, "Cell Wall Significance", 0.25, 5.05, 6.1, 1.85, [
    "Mycolic acids + arabinogalactan + peptidoglycan",
    "Low permeability → intrinsic drug resistance",
    "Stimulates granuloma formation via TLR2/TLR4 signaling"
], font_size=12.5)

section_box(s, "Staining Methods", 6.6, 5.05, 6.45, 1.85, [
    "Ziehl-Neelsen (ZN): hot carbol fuchsin → red bacilli on blue BG",
    "Auramine-rhodamine: fluorescence microscopy (more sensitive)",
    "Both detect AFBs but NOT species-specific"
], font_size=12.5)

add_text(s, "Source: Harrison's Principles of Internal Medicine 22E, Chapter 183",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 4 — Pathogenesis & Transmission
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Pathogenesis & Transmission")

section_box(s, "Transmission", 0.25, 1.28, 4.1, 2.8, [
    "Airborne — droplet nuclei (1-5 μm)",
    "Produced by coughing, sneezing, speaking",
    "Can remain suspended in air for hours",
    "1-10 bacilli per droplet nucleus sufficient",
    "NOT via fomites or brief contact",
    "Infectiousness ↑ with: cavitary disease, smear+ve, laryngeal TB"
], font_size=12)

section_box(s, "Outcomes after Inhalation", 4.6, 1.28, 4.55, 2.8, [
    "Immediate clearance (strong innate immunity)",
    "Primary progressive TB (immunocompromised/infants)",
    "Latent TB infection / LTBI (most common ~90%)",
    "Reactivation TB (lifetime risk 5-10%)",
    "Disseminated/miliary TB (hematogenous)"
], font_size=12)

section_box(s, "Granuloma Formation", 9.4, 1.28, 3.65, 2.8, [
    "Hallmark of TB pathology",
    "Macrophages engulf bacilli → attract CD4+ T cells",
    "Central caseous necrosis",
    "Surrounded by epithelioid macrophages",
    "Langhans giant cells (peripheral nuclei)",
    "Outer ring of lymphocytes",
    "Key cytokines: TNF-α, IFN-γ, IL-12"
], font_size=12)

section_box(s, "Risk Factors — Progression from LTBI to Active TB", 0.25, 4.25, 12.8, 2.7, [
    ("HIV infection", C_ACCENT, " — Greatest risk; 5-10% per year (vs. 0.1% lifetime in HIV-negative)"),
    ("TNF-α inhibitors", C_ACCENT, " — Infliximab, adalimumab (screen before starting)"),
    ("Recent infection", C_MED_BLUE, " — Within last 2 years"),
    ("Diabetes mellitus", C_MED_BLUE, " — 3x increased risk"),
    ("Silicosis", C_MED_BLUE, " — 30x increased risk"),
    ("Chronic kidney disease, malnutrition, malignancy (esp. hematologic)", C_TEXT_DARK, ""),
    ("Extremes of age (infants, elderly), corticosteroids, other immunosuppressants", C_TEXT_DARK, "")
], font_size=12, text_color=C_TEXT_DARK)

add_text(s, "Source: Harrison's Principles of Internal Medicine 22E, Chapter 183",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 5 — Clinical Features: Pulmonary TB
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Clinical Features — Pulmonary TB", "Most common form (~2/3 of all TB cases)")

section_box(s, "Primary TB", 0.25, 1.28, 4.1, 2.7, [
    "Often asymptomatic or mild",
    "Ghon focus: subpleural parenchymal lesion",
    "Ghon complex = Ghon focus + hilar LN",
    "May progress to effusion or dissemination",
    "Children and immunocompromised at risk",
    "Usually self-limiting in immunocompetent"
], font_size=12)

section_box(s, "Reactivation (Post-Primary) TB", 4.6, 1.28, 4.55, 2.7, [
    "Weeks-to-months history",
    "Productive cough ± hemoptysis",
    "Fever (low-grade, afternoon)",
    "Drenching night sweats",
    "Weight loss, anorexia, fatigue",
    "Upper lobe predilection (high O₂)",
    "Signs: crackles, bronchial breathing"
], font_size=12)

section_box(s, "Chest X-Ray / CT Findings", 9.4, 1.28, 3.65, 2.7, [
    "Upper lobe infiltrates / consolidation",
    "Cavitation (pathognomonic when present)",
    "Tree-in-bud pattern on CT",
    "Centrilobular nodules (endobronchial spread)",
    "Fibrotic streaks, calcification (healed)",
    "Bilateral in severe disease",
    "Miliary pattern (disseminated)"
], font_size=12)

# Complications section
section_box(s, "Complications of Pulmonary TB", 0.25, 4.15, 12.8, 2.75, [
    ("Hemoptysis", C_ACCENT, " — Erosion of Rasmussen's aneurysm; massive hemoptysis is life-threatening"),
    ("Pneumothorax", C_ACCENT, " — Rupture of subpleural cavity"),
    ("Bronchopleural fistula", C_MED_BLUE, " — Cavity connects to pleural space"),
    ("Aspergilloma", C_MED_BLUE, " — Fungal colonization of residual cavity (Aspergillus)"),
    ("Cor pulmonale", C_TEXT_DARK, " — End-stage fibrotic disease with pulmonary hypertension"),
    ("Amyloidosis (AA type)", C_TEXT_DARK, " — Chronic inflammation → secondary amyloidosis")
], font_size=12, text_color=C_TEXT_DARK)

add_text(s, "Source: Harrison's Principles of Internal Medicine 22E, Chapter 183",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 6 — Extrapulmonary TB
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Extrapulmonary Tuberculosis", "Up to 1/3 of all TB cases; higher in HIV/AIDS")

data = [
    ("Lymph Node TB\n(most common EPTB, 35%)", "Painless cervical/supraclavicular swelling (scrofula)\nFNAC yield ~80%; may form discharging sinus", C_MED_BLUE),
    ("Pleural TB\n(~20% of EPTB)", "Exudative effusion; lymphocyte-predominant\nADA >40 U/L; protein >3 g/dL; pH ~7.3", C_MED_BLUE),
    ("TB Meningitis\n(most severe)", "Subacute onset; basal meningitis; CN palsies\nHydrocephalus; CSF: lymphocytes, high protein, low glucose", C_ACCENT),
    ("Spinal TB\n(Pott's disease)", "Thoracic > lumbar vertebrae; vertebral body destruction\nGibbus deformity; paravertebral cold abscess", C_ACCENT),
    ("Genitourinary TB", "Sterile pyuria; dysuria; hematuria\nRenal parenchymal destruction; ureteric stricture", C_DARK_BLUE),
    ("Peritoneal / Abdominal TB", "Ascites (doughy abdomen); ileocaecal involvement\nObstruction; ADA >33 U/L in ascitic fluid", C_DARK_BLUE),
]

col_w = 6.35
for idx, (title, body, col) in enumerate(data):
    col_num = idx % 2
    row_num = idx // 2
    x = 0.25 + col_num * (col_w + 0.28)
    y = 1.35 + row_num * 1.9
    add_rect(s, x, y, col_w, 0.42, col)
    add_text(s, title, x+0.1, y+0.03, col_w-0.15, 0.4,
             font_size=11.5, bold=True, color=C_WHITE)
    add_rect(s, x, y+0.42, col_w, 1.38, C_LIGHT_BG)
    add_multiline(s, body.split("\n"), x+0.1, y+0.46, col_w-0.15, 1.28,
                  font_size=11.5, text_color=C_TEXT_DARK, bullet=False)

add_rect(s, 0.25, 7.02, 12.8, 0.35, RGBColor(0xD0,0xE4,0xF8))
add_text(s, "Note: TB pericarditis, miliary TB, and bone/joint TB are additional important sites.  |  Adjunct steroids recommended in TB meningitis and TB pericarditis",
         0.35, 7.04, 12.6, 0.3, font_size=10, color=C_DARK_BLUE)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 7 — Diagnosis
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Diagnosis of Tuberculosis", "NTEP: GeneXpert is first-line molecular test in India")

# Left column
section_box(s, "Tuberculin Skin Test (TST / Mantoux)", 0.25, 1.28, 6.1, 1.85, [
    "5 TU PPD intradermal; read at 48-72 hrs",
    "≥5 mm: HIV+, close contacts, immunosuppressed, abnormal CXR",
    "≥10 mm: HCW, immigrants, DM, CKD, prisoners",
    "≥15 mm: low-risk individuals",
    "Limitations: False+ve (BCG, NTM); False-ve (anergy in advanced TB/HIV)"
], font_size=11.5)

section_box(s, "IGRA (Interferon-Gamma Release Assay)", 0.25, 3.3, 6.1, 1.7, [
    "QuantiFERON-TB Gold Plus, T-SPOT.TB",
    "Detects IFN-γ response to ESAT-6 and CFP-10",
    "More specific than TST (not affected by BCG)",
    "Preferred in India for LTBI diagnosis",
    "Cannot distinguish LTBI from active TB"
], font_size=11.5)

section_box(s, "Other Tests", 0.25, 5.15, 6.1, 1.75, [
    "ADA (Adenosine Deaminase): pleural >40, CSF >10, ascites >33 U/L",
    "Bronchoscopy + BAL: when sputum unavailable",
    "Biopsy: lymph node FNAC (yield ~80%); pleural biopsy",
    "Histopathology: caseating granuloma with Langhans giant cells"
], font_size=11.5)

# Right column — microbiological tests table
add_rect(s, 6.6, 1.28, 6.45, 5.62, C_LIGHT_BG)
add_rect(s, 6.6, 1.28, 6.45, 0.42, C_DARK_BLUE)
add_text(s, "Microbiological / Molecular Diagnosis", 6.72, 1.30, 6.2, 0.38,
         font_size=13, bold=True, color=C_WHITE)

rows = [
    ("AFB Smear (ZN/Auramine)", "40-60%", "Rapid, cheap; requires 5,000+ AFB/mL"),
    ("Culture (LJ / MGIT)", "80-90% (gold std)", "3-8 wks (LJ) or 10-14 days (MGIT liquid)"),
    ("Xpert MTB/RIF", "88% (smear+ve)\n68% (smear-ve)", "Detects MTB + RIF resistance in ~2 hrs\nFirst-line in NTEP India"),
    ("Xpert Ultra", "Higher sensitivity", "Better for EPTB, paucibacillary disease"),
    ("LPA (Line Probe Assay)", "High for H+R resistance", "Detects H and R resistance; done on smear+ve"),
]
col_xs = [6.65, 9.05, 10.25]
col_ws = [2.35, 1.15, 2.7]
headers = ["Test", "Sensitivity", "Comments"]
for ci, (h, cx, cw) in enumerate(zip(headers, col_xs, col_ws)):
    add_rect(s, cx, 1.72, cw, 0.35, C_MED_BLUE)
    add_text(s, h, cx+0.05, 1.73, cw-0.08, 0.33,
             font_size=10.5, bold=True, color=C_WHITE, align=PP_ALIGN.CENTER)

row_colors = [C_WHITE, RGBColor(0xE8, 0xF0, 0xFB)]
for ri, (test, sens, comment) in enumerate(rows):
    row_bg = row_colors[ri % 2]
    row_y = 2.09 + ri * 0.88
    for ci, (val, cx, cw) in enumerate(zip([test, sens, comment], col_xs, col_ws)):
        add_rect(s, cx, row_y, cw, 0.86, row_bg)
        add_text(s, val, cx+0.05, row_y+0.02, cw-0.08, 0.82,
                 font_size=10, bold=(ci == 0), color=C_TEXT_DARK, wrap=True)

add_text(s, "Source: Harrison's 22E | NTEP Technical Guidelines",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 8 — Treatment: LTBI + DS-TB (Harrison's)
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Treatment of TB — Drug-Susceptible Disease", "Harrison's 22E | ATS/CDC/ERS/IDSA 2025 Guidelines")

# LTBI
add_rect(s, 0.25, 1.28, 12.8, 0.42, C_MED_BLUE)
add_text(s, "LATENT TB INFECTION (LTBI) Treatment Regimens", 0.4, 1.3, 12.5, 0.38,
         font_size=14, bold=True, color=C_WHITE)

ltbi_rows = [
    ("3HP (PREFERRED)", "INH 900mg + Rifapentine 900mg Weekly", "3 months", "1st choice in adults & children >2 yrs incl. HIV+; NOT in pregnancy; pyridoxine supplement"),
    ("4R", "Rifampin 600mg daily", "4 months", "HIV-negative preferred; no definitive data in HIV+; preferred over 6-9H"),
    ("3HR", "INH 300mg/d + RIF 600mg/d", "3 months", "Caution in HIV (drug interactions, possible rifampin resistance)"),
    ("6H or 9H", "INH 300mg/d or 900mg twice weekly", "6-9 months", "Older standard; 9 months more effective but higher hepatotoxicity; twice-weekly needs DOT"),
]
ltbi_col_xs = [0.25, 3.0, 7.5, 9.3]
ltbi_col_ws = [2.7, 4.45, 1.75, 3.8]
ltbi_headers = ["Regimen", "Drug / Dose", "Duration", "Comments"]

for ci, (h, cx, cw) in enumerate(zip(ltbi_headers, ltbi_col_xs, ltbi_col_ws)):
    add_rect(s, cx, 1.72, cw, 0.32, C_DARK_BLUE)
    add_text(s, h, cx+0.05, 1.73, cw-0.08, 0.3,
             font_size=10, bold=True, color=C_GOLD, align=PP_ALIGN.CENTER)

for ri, (reg, drug, dur, comm) in enumerate(ltbi_rows):
    row_bg = [C_WHITE, C_LIGHT_BG][ri % 2]
    ry = 2.06 + ri * 0.52
    for val, cx, cw, is_reg in zip([reg, drug, dur, comm],
                                    ltbi_col_xs, ltbi_col_ws,
                                    [True, False, False, False]):
        add_rect(s, cx, ry, cw, 0.5, row_bg)
        add_text(s, val, cx+0.05, ry+0.02, cw-0.08, 0.46,
                 font_size=9.5, bold=is_reg, color=C_DARK_BLUE if is_reg else C_TEXT_DARK, wrap=True)

# Active DS-TB
add_rect(s, 0.25, 4.22, 12.8, 0.42, C_ACCENT)
add_text(s, "ACTIVE TB — Drug-Susceptible Disease (DS-TB)", 0.4, 4.24, 12.5, 0.38,
         font_size=14, bold=True, color=C_WHITE)

section_box(s, "Standard 6-Month Regimen: 2HRZE / 4HR", 0.25, 4.66, 6.1, 2.22, [
    "Intensive Phase (2 months): H + R + Z + E daily",
    "Continuation Phase (4 months): H + R daily",
    "Extend to 9 months (2HRZE/7HR) if:",
    "  — Cavitary disease",
    "  — 2-month pyrazinamide course not completed",
    "  — Sputum culture positive at month 2"
], font_size=12)

section_box(s, "NEW 4-Month Regimen (TBTC S31 Trial, 2020) — ATS/CDC/ERS Conditional Recommendation", 6.6, 4.66, 6.45, 2.22, [
    "2 months: Rifapentine + INH + PZA + Moxifloxacin (daily)",
    "Then ~9 weeks: Rifapentine + INH + Moxifloxacin (daily)",
    "Noninferior to standard 6-month HRZE in large RCT",
    "Includes HIV patients with CD4 >100",
    "No ethambutol in this regimen"
], font_size=12)

add_text(s, "H=Isoniazid | R=Rifampin | Z=Pyrazinamide | E=Ethambutol | P=Rifapentine | M=Moxifloxacin",
         0.25, 7.1, 12.8, 0.3, font_size=9.5, color=RGBColor(0x44,0x44,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 9 — First-Line Drug Profiles
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "First-Line Anti-TB Drug Profiles", "Doses, Mechanisms & Adverse Effects")

drugs = [
    ("Isoniazid (H)", "5 mg/kg/d\nmax 300 mg/d", "Inhibits mycolic acid synthesis\n(InhA enzyme, KatG activation)", "Hepatotoxicity (↑ with age/alcohol)\nPeripheral neuropathy (prevent with pyridoxine 25-50 mg/d)\nLupus-like syndrome, seizures", C_DARK_BLUE),
    ("Rifampin (R)", "10 mg/kg/d\nmax 600 mg/d", "Inhibits RNA polymerase\n(β-subunit, rpoB gene)", "Hepatotoxicity\nOrange discoloration of secretions\nPotent CYP450 inducer (↑↑ drug interactions)\nFlu-like syndrome (intermittent use)", C_MED_BLUE),
    ("Pyrazinamide (Z)", "25 mg/kg/d\nmax 2 g/d", "Disrupts membrane energetics\n(active in acidic environment)", "Hepatotoxicity (most common cause)\nHyperuricemia / Gout\nArthralgia, rash, photosensitivity", C_ACCENT),
    ("Ethambutol (E)", "15-20 mg/kg/d", "Inhibits arabinogalactan synthesis\n(embB gene)", "Optic neuritis: color blindness, ↓visual acuity\nCheck vision before and during treatment\nAvoid in young children (monitoring difficult)", C_GREEN),
    ("Streptomycin (S)", "15 mg/kg IM/IV", "Inhibits 30S ribosomal subunit\n(protein synthesis)", "Ototoxicity (vestibular > cochlear)\nNephrotoxicity\nCONTRAINDICATED in pregnancy", C_ORANGE),
]

col_titles = ["Drug", "Dose (Adult)", "Mechanism", "Key Adverse Effects"]
col_xs = [0.25, 2.5, 4.55, 8.2]
col_ws = [2.2, 2.0, 3.6, 4.85]

for ci, (h, cx, cw) in enumerate(zip(col_titles, col_xs, col_ws)):
    add_rect(s, cx, 1.28, cw, 0.38, C_DARK_BLUE)
    add_text(s, h, cx+0.06, 1.3, cw-0.1, 0.35,
             font_size=12, bold=True, color=C_GOLD, align=PP_ALIGN.CENTER)

for ri, (name, dose, mech, adv, dc) in enumerate(drugs):
    ry = 1.68 + ri * 1.06
    # Drug name cell
    add_rect(s, col_xs[0], ry, col_ws[0], 1.04, dc)
    add_text(s, name, col_xs[0]+0.06, ry+0.08, col_ws[0]-0.1, 0.88,
             font_size=12, bold=True, color=C_WHITE, v_anchor=MSO_ANCHOR.MIDDLE)
    # Dose
    row_bg = [C_WHITE, C_LIGHT_BG][ri % 2]
    add_rect(s, col_xs[1], ry, col_ws[1], 1.04, row_bg)
    add_text(s, dose, col_xs[1]+0.06, ry+0.04, col_ws[1]-0.1, 0.96,
             font_size=11, bold=False, color=C_TEXT_DARK, wrap=True)
    # Mechanism
    add_rect(s, col_xs[2], ry, col_ws[2], 1.04, row_bg)
    add_text(s, mech, col_xs[2]+0.06, ry+0.04, col_xs[3]-col_xs[2]-0.1, 0.96,
             font_size=10.5, bold=False, color=C_TEXT_DARK, wrap=True)
    # Adverse
    add_rect(s, col_xs[3], ry, col_ws[3], 1.04, row_bg)
    add_text(s, adv, col_xs[3]+0.06, ry+0.04, col_ws[3]-0.1, 0.96,
             font_size=10.5, bold=False, color=C_TEXT_DARK, wrap=True)

add_text(s, "Source: Harrison's Principles of Internal Medicine 22E | NTEP Drug Manual",
         0.25, 7.08, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 10 — NTEP India: DS-TB Management
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "NTEP India — Drug-Susceptible TB Management", "National TB Elimination Programme | MoHFW 2025")

section_box(s, "Key Changes from RNTCP → NTEP", 0.25, 1.28, 6.1, 2.6, [
    "Thrice-weekly DOT ABOLISHED → DAILY regimen (FDC)",
    "Cat I / Cat II system ABOLISHED → DST-based individualized Rx",
    "Mandatory notification: ALL providers (public + private)",
    "Universal DST: All confirmed TB → Xpert MTB/RIF first",
    "Daily FDC tablets (weight-band based)",
    "Nikshay IT system: case tracking, treatment monitoring"
], font_size=12)

section_box(s, "DS-TB Treatment (2HRZE / 4HR — Daily FDC)", 6.6, 1.28, 6.45, 2.6, [
    "FDC tablet: INH 75mg + RIF 150mg + PZA 400mg + EMB 275mg",
    "Weight ≤39 kg: 2 tablets; 40-54 kg: 3 tablets",
    "55-69 kg: 4 tablets; ≥70 kg: 5 tablets",
    "Extension to 12 months: CNS TB, Spinal TB, Bone/Joint TB",
    "Miliary TB: treat as 2HRZE/10HR (12 months)",
    "Pyridoxine (B6) supplement with INH in all cases"
], font_size=12)

section_box(s, "TB Preventive Treatment (TPT) — NTEP 2021", 0.25, 4.04, 6.1, 2.85, [
    "Indications: HIV+, household contacts <5 yrs, immunosuppressed",
    "6H: INH 5-10 mg/kg/d (max 300mg) × 6 months",
    "3HP: INH + Rifapentine weekly × 3 months",
    "1HP: INH + Rifapentine daily × 1 month (HIV+, conditional)",
    "Screen for active TB before starting TPT",
    "Do NOT start TPT if active TB suspected"
], font_size=12)

section_box(s, "Special Populations (NTEP)", 6.6, 4.04, 6.45, 2.85, [
    "TB in children: weight-based dosing; ethionamide replaces EMB <5 yrs",
    "TB-HIV: start ART within 2 weeks (CD4<50) or 8 weeks (others)",
    "Use efavirenz-based ART with rifampin-containing regimens",
    "Pregnancy: H, R, Z safe; Streptomycin CONTRAINDICATED",
    "Renal impairment: reduce PZA, EMB doses; avoid aminoglycosides",
    "Monitor for IRIS in TB-HIV (incidence 15-30%)"
], font_size=12)

add_text(s, "Source: NTEP Technical & Operational Guidelines | Central TB Division, MoHFW India 2025",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 11 — Drug-Resistant TB Classification
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Drug-Resistant TB — Classification & Drug Groups", "NTEP / WHO 2022 Updated Classification")

# DR-TB classification table
add_rect(s, 0.25, 1.28, 12.8, 0.38, C_DARK_BLUE)
add_text(s, "DR-TB Classification", 0.4, 1.30, 12.5, 0.35,
         font_size=14, bold=True, color=C_WHITE)

dr_rows = [
    ("Mono-resistance", "Resistant to 1 first-line drug only", C_GREEN),
    ("Poly-resistance", "Resistant to >1 first-line drug (NOT the combination H+R)", C_GREEN),
    ("RR-TB\n(Rifampicin-Resistant)", "Any Rifampin resistance (with or without other resistance)\nTreated as MDR-TB", C_MED_BLUE),
    ("MDR-TB", "Resistant to BOTH Isoniazid AND Rifampin\nMost important category", C_ACCENT),
    ("Pre-XDR-TB\n(WHO 2021 definition)", "MDR/RR-TB + resistance to ANY Fluoroquinolone", RGBColor(0xB0,0x30,0xB0)),
    ("XDR-TB", "MDR/RR-TB + Fluoroquinolone resistance + Bedaquiline or Linezolid resistance", C_DARK_BLUE),
]

for ri, (cat, defn, col) in enumerate(dr_rows):
    ry = 1.7 + ri * 0.7
    add_rect(s, 0.25, ry, 3.5, 0.68, col)
    add_text(s, cat, 0.35, ry+0.04, 3.3, 0.6,
             font_size=11.5, bold=True, color=C_WHITE, v_anchor=MSO_ANCHOR.MIDDLE)
    row_bg = [C_WHITE, C_LIGHT_BG][ri % 2]
    add_rect(s, 3.77, ry, 9.3, 0.68, row_bg)
    add_text(s, defn, 3.87, ry+0.04, 9.1, 0.6,
             font_size=11.5, bold=False, color=C_TEXT_DARK, wrap=True)

# Drug groups
add_rect(s, 0.25, 6.02, 12.8, 0.38, C_MED_BLUE)
add_text(s, "WHO / NTEP Drug Groups for MDR-TB Treatment", 0.4, 6.04, 12.5, 0.35,
         font_size=13, bold=True, color=C_WHITE)

groups = [
    ("Group A\n(Use ALL 3)", "Levofloxacin / Moxifloxacin\nBedaquiline (Bdq)\nLinezolid (Lzd)", C_GREEN),
    ("Group B\n(Add 1-2)", "Clofazimine (Cfz)\nCycloserine (Cs) / Terizidone", C_MED_BLUE),
    ("Group C\n(Add to complete regimen)", "Ethambutol, Delamanid, PZA\nImipenem-cilastatin, Amikacin\nEthionamide/Pto, PAS", C_DARK_BLUE),
]
gx = [0.25, 4.5, 8.75]
gw = 4.1
for (gtitle, gdrugs, gcol), gxi in zip(groups, gx):
    add_rect(s, gxi, 6.42, gw, 0.35, gcol)
    add_text(s, gtitle, gxi+0.08, 6.43, gw-0.12, 0.33,
             font_size=11, bold=True, color=C_WHITE)
    add_rect(s, gxi, 6.79, gw, 0.6, C_LIGHT_BG)
    add_text(s, gdrugs, gxi+0.08, 6.8, gw-0.12, 0.58,
             font_size=10, bold=False, color=C_TEXT_DARK, wrap=True)

add_text(s, "Source: WHO 2022 Consolidated Guidelines | NTEP National Guidelines for DR-TB Management March 2025",
         0.25, 7.38, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 12 — MDR-TB Treatment Regimens (NTEP 2025)
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "MDR-TB Treatment — NTEP India 2025", "National Guidelines for Management of DR-TB — March 27, 2025")

# BPaLM box
add_rect(s, 0.25, 1.28, 6.1, 3.1, RGBColor(0xE8,0xF8,0xE8))
add_rect(s, 0.25, 1.28, 6.1, 0.42, C_GREEN)
add_text(s, "BPaLM Regimen (PREFERRED for FQ-susceptible MDR/RR-TB)", 0.35, 1.30, 5.9, 0.38,
         font_size=12, bold=True, color=C_WHITE)
add_multiline(s, [
    "Bedaquiline + Pretomanid + Linezolid + Moxifloxacin",
    "Duration: 6 months (all-oral, shorter)",
    "Bdq: 400mg/d × 2 wks → 200mg 3×/wk × 24 wks",
    "Pretomanid: 200mg daily × 26 weeks",
    "Linezolid: 600mg daily × 26 weeks",
    "Evidence: TB-PRACTECAL trial (2022) — superior to standard of care",
    "WHO Conditional Recommendation | NTEP 2025 adopted"
], 0.33, 1.73, 5.9, 2.55, font_size=11.5, text_color=C_TEXT_DARK)

# BPaL box
add_rect(s, 6.6, 1.28, 6.45, 3.1, RGBColor(0xFFF5E8))
add_rect(s, 6.6, 1.28, 6.45, 0.42, C_ORANGE)
add_text(s, "BPaL Regimen (for FQ-RESISTANT MDR/RR-TB or XDR-TB)", 6.7, 1.30, 6.25, 0.38,
         font_size=12, bold=True, color=C_WHITE)
add_multiline(s, [
    "Bedaquiline + Pretomanid + Linezolid",
    "Duration: 6 months",
    "Same drug doses as BPaLM (without Moxifloxacin)",
    "Evidence: ZeNix trial (2022)",
    "Lzd 600mg preferred (vs 1200mg: less toxic, comparable efficacy)",
    "Used when FQ resistance confirmed or suspected"
], 6.68, 1.73, 6.27, 2.55, font_size=11.5, text_color=C_TEXT_DARK)

# Shorter 9-11 month regimen
section_box(s, "Shorter MDR-TB Oral Regimen (9-11 months) — STREAM Stage 1", 0.25, 4.55, 6.1, 2.4, [
    "For FQ-susceptible MDR-TB without Group A drug resistance",
    "Intensive (4-6m): Bdq + Mfx/Lfx + Cfz + Z + E + H(HD) + Eto/Pto",
    "Continuation (5m): Mfx/Lfx + Cfz + Z + E",
    "Delamanid may be added in complex cases",
    "Monthly sputum culture mandatory"
], font_size=11.5)

section_box(s, "Longer Regimen (18-20 months) for Pre-XDR/XDR-TB", 6.6, 4.55, 6.45, 2.4, [
    "When BPaL/BPaLM not feasible or resistance to Bdq/Lzd",
    "At least 5 active drugs in intensive phase",
    "Use all available Group A + B + C drugs",
    "Delamanid: 100mg BD × 24 weeks as add-on",
    "QTc monitoring essential (Bdq + Dlm + Cfz combination)",
    "Individualized by DR-TB expert committee"
], font_size=11.5)

add_text(s, "Bdq=Bedaquiline | Pa=Pretomanid | L=Linezolid | M=Moxifloxacin | Cfz=Clofazimine | Dlm=Delamanid | Eto=Ethionamide",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x44,0x44,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 13 — DR-TB Monitoring & Adverse Effects
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "DR-TB Treatment Monitoring", "Adverse Effect Surveillance During Treatment")

# Monitoring table
add_rect(s, 0.25, 1.28, 7.0, 0.38, C_DARK_BLUE)
add_text(s, "Monitoring Schedule", 0.4, 1.3, 6.7, 0.35,
         font_size=13, bold=True, color=C_WHITE)

mon_rows = [
    ("Sputum smear + culture", "Monthly during intensive phase; every 2m in continuation"),
    ("ECG (QTc interval)", "Baseline → monthly (Bdq, Dlm, Cfz, Mfx all prolong QT)"),
    ("Liver function tests (LFT)", "Baseline → monthly (Lzd, Eto, PZA hepatotoxic)"),
    ("Complete Blood Count (CBC)", "Monthly (Linezolid: myelosuppression, anaemia)"),
    ("Peripheral neuropathy check", "Monthly (Linezolid, Cycloserine)"),
    ("Visual acuity / colour vision", "Baseline + every 6m (Ethambutol, Linezolid)"),
    ("Thyroid function (TSH)", "Baseline + every 6m (Ethionamide + PAS)"),
    ("Renal function (creatinine)", "Monthly if aminoglycosides used (ototoxicity, nephrotoxicity)"),
    ("Audiometry", "Baseline + regular if aminoglycosides used"),
    ("Psychiatric/mood assessment", "Monthly (Cycloserine: psychosis, depression)"),
]
for ri, (test, freq) in enumerate(mon_rows):
    ry = 1.68 + ri * 0.5
    row_bg = [C_WHITE, C_LIGHT_BG][ri % 2]
    add_rect(s, 0.25, ry, 3.3, 0.48, row_bg)
    add_text(s, test, 0.32, ry+0.02, 3.15, 0.44,
             font_size=11, bold=True, color=C_DARK_BLUE)
    add_rect(s, 3.57, ry, 3.65, 0.48, row_bg)
    add_text(s, freq, 3.64, ry+0.02, 3.5, 0.44,
             font_size=11, bold=False, color=C_TEXT_DARK, wrap=True)

# Right panel: key adverse effects
section_box(s, "Key Drug Adverse Effects", 7.5, 1.28, 5.55, 5.75, [
    ("Bedaquiline:", C_ACCENT, " QTc prolongation, hepatotoxicity, nausea"),
    ("Linezolid:", C_ACCENT, " Myelosuppression, peripheral/optic neuropathy, lactic acidosis"),
    ("Pretomanid:", C_MED_BLUE, " Hepatotoxicity, peripheral neuropathy, QTc prolongation"),
    ("Moxifloxacin:", C_MED_BLUE, " QTc prolongation, tendinopathy, photosensitivity"),
    ("Clofazimine:", C_MED_BLUE, " Skin discoloration (orange-brown), QTc prolongation"),
    ("Delamanid:", C_DARK_BLUE, " QTc prolongation, hepatotoxicity, dizziness"),
    ("Cycloserine:", C_DARK_BLUE, " Psychosis, seizures, depression, peripheral neuropathy"),
    ("Ethionamide:", C_DARK_BLUE, " Nausea, hepatotoxicity, hypothyroidism (with PAS)"),
    ("Amikacin:", C_TEXT_DARK, " Ototoxicity (irreversible), nephrotoxicity"),
    ("Note:", C_ACCENT, " Avoid Bdq + Dlm + Mfx together without rigorous QTc monitoring"),
], font_size=11.5, text_color=C_TEXT_DARK, bg_color=RGBColor(0xFF, 0xF5, 0xF5))

add_text(s, "Source: NTEP National Guidelines for DR-TB Management March 2025 | ZeNix & TB-PRACTECAL trials",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 14 — NTEP Programmatic Initiatives
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "NTEP — Key Programmatic Initiatives (India 2025)", "National Tuberculosis Elimination Programme | PM TB Mukt Bharat")

initiatives = [
    ("Nikshay IT Platform", "Mandatory case notification system for all public and private providers\nReal-time treatment tracking, outcome reporting, DST results", C_DARK_BLUE),
    ("Nikshay Poshan Yojana", "₹500/month direct benefit transfer (DBT) to all TB patients\nNutritional support throughout treatment duration", C_GREEN),
    ("Nikshay Mitra Initiative", "Corporate/NGO/individual adoption of TB patients\nProvides nutritional, diagnostic & vocational support\nUpdated guidelines 2026", C_MED_BLUE),
    ("PM TB Mukt Bharat Abhiyaan", "PM-level national campaign for TB elimination\nDistrict-level targets; 5 years ahead of global SDG timeline\nTB-free India by 2025 target", C_ACCENT),
    ("Universal DST (UDST)", "All bacteriologically confirmed TB → Xpert MTB/RIF\nCulture + DST for all presumptive DR-TB patients\nRapid molecular testing at district level", C_DARK_BLUE),
    ("Differentiated TB Care (2025)", "Risk-stratified approach: high-risk patients identified\nIntensified monitoring for vulnerable groups\nNew guidance issued March 2025", C_MED_BLUE),
    ("Active Case Finding (ACF)", "Systematic screening in tribal areas, urban slums, prisons\nTargeted screening: PLWH, DM, silicosis, healthcare workers", C_GREEN),
    ("Daily FDC Regimen", "Replaced intermittent thrice-weekly DOTS\nWeight-band based fixed-dose combinations\nImproves adherence and reduces acquired resistance", C_ORANGE),
]

for idx, (title, body, col) in enumerate(initiatives):
    col_num = idx % 2
    row_num = idx // 2
    x = 0.25 + col_num * 6.6
    y = 1.35 + row_num * 1.45
    bw = 6.35
    add_rect(s, x, y, bw, 0.38, col)
    add_text(s, title, x+0.08, y+0.03, bw-0.12, 0.34,
             font_size=12, bold=True, color=C_WHITE)
    add_rect(s, x, y+0.38, bw, 0.97, C_LIGHT_BG)
    add_text(s, body, x+0.1, y+0.42, bw-0.18, 0.9,
             font_size=11, bold=False, color=C_TEXT_DARK, wrap=True)

add_text(s, "Source: Central TB Division, MoHFW India | tbcindia.mohfw.gov.in | NSP 2020-2025",
         0.25, 7.25, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 15 — TB-HIV Co-infection
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "TB-HIV Co-infection — Management", "Harrison's 22E | NTEP / NACO Guidelines India")

section_box(s, "Epidemiology & Pathogenesis", 0.25, 1.28, 6.1, 2.4, [
    "HIV is greatest risk factor for LTBI → active TB (5-10%/year)",
    "Extrapulmonary TB more common in HIV",
    "Atypical CXR presentations (lower lobe, miliary)",
    "Smear-negative TB more frequent",
    "Granulomas less well-organized; higher bacterial loads",
    "Mortality significantly higher if untreated"
], font_size=12)

section_box(s, "ART Timing (Critical Decision)", 6.6, 1.28, 6.45, 2.4, [
    "Start ART within 2 WEEKS if CD4 <50 cells/μL",
    "Start ART within 8 WEEKS if CD4 ≥50 cells/μL",
    "ART must not be delayed in TB meningitis (risk of IRIS)",
    "Exception: TB meningitis — delay ART 4-8 weeks (high IRIS risk)",
    "Efavirenz-based ART preferred with rifampin-containing TB regimens",
    "Rifabutin substituted for Rifampin when using PIs"
], font_size=12)

section_box(s, "Drug Interactions", 0.25, 3.85, 6.1, 2.0, [
    "Rifampin: potent CYP3A4 inducer → ↓ PI levels (>75%)",
    "Use efavirenz 600mg/d (dose adjustment not needed)",
    "Rifabutin (150mg/d) with PIs: less interaction",
    "Integrase inhibitors (dolutegravir): double dose with rifampin",
    "Monitor for overlapping hepatotoxicity (rifampin + NVP)"
], font_size=12)

section_box(s, "IRIS (Immune Reconstitution Inflammatory Syndrome)", 6.6, 3.85, 6.45, 2.0, [
    "Incidence: 15-30% after ART initiation in TB patients",
    "Paradoxical worsening of TB symptoms after ART",
    "Typically 2-8 weeks after starting ART",
    "Manage with NSAIDs; steroids for severe IRIS",
    "Do NOT stop ART or anti-TB treatment",
    "High-risk: CD4 <50, disseminated TB"
], font_size=12)

section_box(s, "Co-trimoxazole Prophylaxis & Other Measures", 0.25, 5.97, 12.8, 1.35, [
    "Co-trimoxazole prophylaxis: ALL TB-HIV patients (prevents PCP, toxoplasma, bacterial infections)",
    "TPT (6H or 3HP): all HIV+ patients without active TB — reduces TB incidence by 60-90%",
    "Nutritional support, Nikshay Poshan Yojana, adherence counseling",
    "HIV VL + CD4 monitoring during anti-TB treatment"
], font_size=12, bg_color=RGBColor(0xE8,0xF0,0xFF))

add_text(s, "Source: Harrison's Principles 22E | NTEP/NACO National Guidelines | WHO 2023 Consolidated HIV Guidelines",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 16 — Treatment Algorithm (India)
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "TB Management Algorithm — India (NTEP 2025)", "Diagnostic & Treatment Pathway")

# Flow diagram using boxes and arrows
box_data = [
    (5.5, 1.3, 2.5, 0.55, "PRESUMPTIVE TB", C_DARK_BLUE, C_WHITE),
    (5.5, 2.25, 2.5, 0.6, "Xpert MTB/RIF\n(First-Line Molecular Test)", C_MED_BLUE, C_WHITE),
]
for bx, by, bw, bh, bt, bc, tc in box_data:
    add_rect(s, bx, by, bw, bh, bc)
    add_text(s, bt, bx+0.06, by+0.04, bw-0.1, bh-0.06,
             font_size=11, bold=True, color=tc, align=PP_ALIGN.CENTER, v_anchor=MSO_ANCHOR.MIDDLE)
    # Arrow
    add_rect(s, bx+bw/2-0.04, by+bh, 0.08, 0.3, C_DARK_BLUE)

# MTB Detected? branch
add_rect(s, 5.5, 3.15, 2.5, 0.5, C_GOLD)
add_text(s, "MTB Detected?", 5.56, 3.17, 2.38, 0.46,
         font_size=11, bold=True, color=C_DARK_BLUE, align=PP_ALIGN.CENTER, v_anchor=MSO_ANCHOR.MIDDLE)

# YES branch left
add_rect(s, 5.5, 3.67, 0.08, 0.38, C_DARK_BLUE)
add_rect(s, 1.0, 4.07, 0.08, 0.3, C_DARK_BLUE)
add_rect(s, 5.5, 4.05, 2.5, 0.5, C_GREEN)
add_text(s, "Rifampin Sensitive?", 5.56, 4.07, 2.38, 0.46,
         font_size=11, bold=True, color=C_WHITE, align=PP_ALIGN.CENTER, v_anchor=MSO_ANCHOR.MIDDLE)

# DS-TB box
add_rect(s, 2.5, 4.85, 3.5, 0.85, RGBColor(0xD8,0xF0,0xD8))
add_rect(s, 2.5, 4.85, 3.5, 0.32, C_GREEN)
add_text(s, "DS-TB (RIF Sensitive)", 2.58, 4.87, 3.35, 0.28,
         font_size=10.5, bold=True, color=C_WHITE)
add_text(s, "2HRZE/4HR — Daily FDC\nWeight-band based dosing\nNotify on Nikshay", 2.58, 5.19, 3.35, 0.48,
         font_size=10, color=C_TEXT_DARK, wrap=True)

# DR-TB box
add_rect(s, 7.4, 4.85, 3.5, 0.85, RGBColor(0xFF,0xEE,0xDD))
add_rect(s, 7.4, 4.85, 3.5, 0.32, C_ACCENT)
add_text(s, "DR-TB (RIF Resistant)", 7.5, 4.87, 3.35, 0.28,
         font_size=10.5, bold=True, color=C_WHITE)
add_text(s, "LPA + Culture/DST\nBPaLM (FQ-sensitive)\nBPaL (FQ-resistant)", 7.5, 5.19, 3.35, 0.48,
         font_size=10, color=C_TEXT_DARK, wrap=True)

# Clinical diagnosis box (MTB not detected)
add_rect(s, 9.4, 3.15, 3.55, 0.75, RGBColor(0xF8,0xF0,0xFF))
add_rect(s, 9.4, 3.15, 3.55, 0.28, RGBColor(0x88,0x44,0xAA))
add_text(s, "MTB Not Detected", 9.48, 3.17, 3.38, 0.26, font_size=10, bold=True, color=C_WHITE)
add_text(s, "Clinical/radiological diagnosis\nif strong suspicion; consider\nEPTB workup", 9.48, 3.45, 3.38, 0.42,
         font_size=10, color=C_TEXT_DARK, wrap=True)

# Bottom: common steps
add_rect(s, 0.25, 6.0, 12.8, 0.38, C_DARK_BLUE)
add_text(s, "FOR ALL CONFIRMED TB:", 0.35, 6.02, 3.5, 0.35, font_size=11, bold=True, color=C_GOLD)
add_text(s, "Notify on Nikshay  |  Nikshay Poshan Yojana (₹500/m)  |  Contact investigation + TPT for eligible  |  Monthly sputum monitoring  |  Adherence support",
         3.85, 6.02, 9.1, 0.35, font_size=10.5, bold=False, color=C_WHITE)

add_rect(s, 0.25, 6.45, 12.8, 0.45, C_LIGHT_BG)
add_text(s, "EPTB: Use Xpert on relevant specimen (CSF, tissue, fluid, urine)  |  Pleural TB: ADA + Xpert on biopsy  |  CNS/Spine/Bone TB: 12 months treatment  |  Adjunct steroids: TB meningitis, TB pericarditis",
         0.35, 6.47, 12.6, 0.4, font_size=10.5, bold=False, color=C_DARK_BLUE, wrap=True)

add_text(s, "Source: NTEP Technical & Operational Guidelines 2025 | Central TB Division, MoHFW India",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SLIDE 17 — Recent Evidence & Summary
# ════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
add_rect(s, 0, 0, 13.333, 7.5, C_WHITE)
slide_header(s, "Recent Evidence & Key Takeaways", "PubMed 2024-2025 | Summary Points")

section_box(s, "Recent Evidence (PubMed 2024-2025)", 0.25, 1.28, 8.1, 4.0, [
    ("BPaL/BPaLM Meta-analysis 2025 (PMID 40172415):", C_ACCENT, " Bdq+Lzd based regimens show superior treatment success and favorable safety vs. traditional longer MDR-TB regimens"),
    ("Shorter MDR-TB Regimens NMA 2024 (PMID 39354416):", C_ACCENT, " 6-month BPaL and BPaLM are most efficacious among all shorter regimens in network meta-analysis"),
    ("Therapeutic Drug Monitoring SR 2025 (PMID 40256853):", C_MED_BLUE, " TDM improves outcomes especially in MDR-TB, HIV co-infection, DM, extremes of weight — being incorporated into NTEP guidance"),
    ("Quinolones as first-line (Meta-analysis 2024):", C_MED_BLUE, " Conditional support for moxifloxacin in 4-month regimen — already reflected in ATS/CDC/ERS 2025 guidelines"),
    ("4-Month Regimen (TBTC S31/A5349 Trial):", C_GREEN, " Rifapentine+INH+PZA+Moxifloxacin noninferior to 6-month HRZE — Conditionally recommended by ATS/CDC/ERS/IDSA 2025"),
], font_size=12, text_color=C_TEXT_DARK)

section_box(s, "Key Takeaways", 8.6, 1.28, 4.45, 4.0, [
    "India = 26% of global TB burden",
    "NTEP: daily FDC, universal DST, mandatory notification",
    "GeneXpert MTB/RIF = first-line diagnostic in India",
    "DS-TB: 2HRZE/4HR (daily FDC)",
    "CNS/Spinal/Bone TB: 12 months treatment",
    "MDR/RR-TB: BPaLM (6m) is new standard",
    "HIV+TB: ART within 2 weeks (CD4<50)",
    "TPT: 6H or 3HP for eligible contacts",
    "Nikshay Poshan Yojana: ₹500/month to all TB patients",
    "QTc monitoring mandatory with Bdq/Dlm/Cfz/Mfx"
], font_size=12.5, text_color=C_TEXT_DARK)

# Treatment outcomes box
add_rect(s, 0.25, 5.42, 12.8, 0.38, C_MED_BLUE)
add_text(s, "NTEP Treatment Outcome Definitions", 0.4, 5.44, 12.4, 0.35,
         font_size=13, bold=True, color=C_WHITE)
outcomes = [
    ("Cured", "Bacteriologically confirmed; negative sputum at end of treatment", C_GREEN),
    ("Completed", "Completed without final bacteriological result", C_MED_BLUE),
    ("Failed", "Positive sputum at month 5 or later", C_ACCENT),
    ("LTFU", "Interrupted ≥2 consecutive months", C_ORANGE),
    ("Died", "Death from any cause during treatment", C_DARK_BLUE),
]
ox = 0.25
for oname, odef, ocol in outcomes:
    ow = 2.54
    add_rect(s, ox, 5.82, ow, 0.35, ocol)
    add_text(s, oname, ox+0.05, 5.83, ow-0.08, 0.33,
             font_size=10.5, bold=True, color=C_WHITE, align=PP_ALIGN.CENTER)
    add_rect(s, ox, 6.19, ow, 0.58, C_LIGHT_BG)
    add_text(s, odef, ox+0.05, 6.2, ow-0.08, 0.55,
             font_size=9.5, color=C_TEXT_DARK, wrap=True, align=PP_ALIGN.CENTER)
    ox += ow + 0.06

add_text(s, "Sources: Harrison's 22E (2025) | NTEP National Guidelines DR-TB March 2025 | ATS/CDC/ERS/IDSA 2025 TB Guidelines | PMIDs 40172415, 39354416, 40256853",
         0.25, 7.1, 12.8, 0.3, font_size=9, color=RGBColor(0x88,0x88,0x88), italic=True)

# ════════════════════════════════════════════════════════════════════════════
# SAVE
# ════════════════════════════════════════════════════════════════════════════
out_path = "/tmp/workspace/tb-ppt/Tuberculosis_Harrison_NTEP_2025.pptx"
buf = BytesIO()
prs.save(buf)
with open(out_path, "wb") as f:
    f.write(buf.getvalue())
print(f"Saved: {out_path}")
print(f"Total slides: {len(prs.slides)}")

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/tb-ppt/create_tb_ppt.py'

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/tb-ppt/create_tb_ppt.py'

"""
TB Management Flowchart — India NTEP 2025 Guidelines
Coloured, detailed, A3 landscape PDF using ReportLab
"""
from reportlab.lib.pagesizes import A3, landscape
from reportlab.lib.units import cm, mm
from reportlab.lib.colors import (
    HexColor, white, black
)
from reportlab.pdfgen import canvas
from reportlab.lib.enums import TA_CENTER, TA_LEFT
from reportlab.platypus import Paragraph
from reportlab.lib.styles import ParagraphStyle
import math

# ── Palette ──────────────────────────────────────────────────────────────────
NAVY      = HexColor("#1A376C")
BLUE      = HexColor("#1E6FB4")
LT_BLUE   = HexColor("#D6E8F8")
GREEN     = HexColor("#1A7A3C")
LT_GREEN  = HexColor("#D6F0E0")
RED       = HexColor("#C0392B")
LT_RED    = HexColor("#FADADD")
ORANGE    = HexColor("#D96500")
LT_ORANGE = HexColor("#FFF0DA")
PURPLE    = HexColor("#6B2FA0")
LT_PURPLE = HexColor("#EEE0FF")
YELLOW    = HexColor("#F5A623")
LT_YELLOW = HexColor("#FFF8E1")
GREY      = HexColor("#F0F4FA")
MID_GREY  = HexColor("#AAAAAA")
TEAL      = HexColor("#0A7B83")
LT_TEAL   = HexColor("#D6F3F5")
WHITE     = white
BLACK     = black

W, H = landscape(A3)   # 42 x 29.7 cm → in points: ~1190 x 842
MARGIN = 18

def make_canvas(path):
    c = canvas.Canvas(path, pagesize=landscape(A3))
    c.setTitle("TB Management Flowchart — NTEP India 2025")
    c.setAuthor("NTEP / Central TB Division, MoHFW India")
    c.setSubject("National Tuberculosis Elimination Programme — Management Guidelines 2025")
    return c

# ── Drawing helpers ───────────────────────────────────────────────────────────

def rect(c, x, y, w, h, fill=GREY, stroke=NAVY, radius=6, stroke_width=1.2, alpha=1):
    c.saveState()
    c.setFillColor(fill)
    c.setStrokeColor(stroke)
    c.setLineWidth(stroke_width)
    c.roundRect(x, y, w, h, radius, fill=1, stroke=1)
    c.restoreState()

def diamond(c, cx, cy, hw, hh, fill=LT_YELLOW, stroke=ORANGE, stroke_width=1.5):
    """Draw a diamond centred at (cx,cy) with half-widths hw, hh"""
    c.saveState()
    c.setFillColor(fill)
    c.setStrokeColor(stroke)
    c.setLineWidth(stroke_width)
    p = c.beginPath()
    p.moveTo(cx, cy + hh)
    p.lineTo(cx + hw, cy)
    p.lineTo(cx, cy - hh)
    p.lineTo(cx - hw, cy)
    p.closePath()
    c.drawPath(p, fill=1, stroke=1)
    c.restoreState()

def arrow(c, x1, y1, x2, y2, color=NAVY, width=1.4, label=None, label_color=NAVY):
    """Draw arrow from (x1,y1) to (x2,y2) with optional label"""
    c.saveState()
    c.setStrokeColor(color)
    c.setFillColor(color)
    c.setLineWidth(width)
    c.line(x1, y1, x2, y2)
    # arrowhead
    angle = math.atan2(y2 - y1, x2 - x1)
    ah = 8
    aw = 5
    ax1 = x2 - ah * math.cos(angle) + aw * math.sin(angle)
    ay1 = y2 - ah * math.sin(angle) - aw * math.cos(angle)
    ax2 = x2 - ah * math.cos(angle) - aw * math.sin(angle)
    ay2 = y2 - ah * math.sin(angle) + aw * math.cos(angle)
    p = c.beginPath()
    p.moveTo(x2, y2)
    p.lineTo(ax1, ay1)
    p.lineTo(ax2, ay2)
    p.closePath()
    c.drawPath(p, fill=1, stroke=0)
    if label:
        mx = (x1 + x2) / 2
        my = (y1 + y2) / 2
        c.setFont("Helvetica-Bold", 8)
        c.setFillColor(label_color)
        c.drawCentredString(mx + 6, my + 3, label)
    c.restoreState()

def text_in_box(c, x, y, w, h, lines, font="Helvetica-Bold", size=9,
                color=BLACK, align="center", v_pad=4):
    """Write multi-line text centred inside a box"""
    c.saveState()
    c.setFont(font, size)
    c.setFillColor(color)
    total_h = len(lines) * (size + 2)
    start_y = y + h / 2 + total_h / 2 - size
    for i, line in enumerate(lines):
        ly = start_y - i * (size + 2)
        if align == "center":
            c.drawCentredString(x + w / 2, ly, line)
        else:
            c.drawString(x + 6, ly, line)
    c.restoreState()

def small_box(c, x, y, w, h, lines, fill, stroke, fsize=8.5, bold=False):
    rect(c, x, y, w, h, fill=fill, stroke=stroke, radius=5)
    font = "Helvetica-Bold" if bold else "Helvetica"
    text_in_box(c, x, y, w, h, lines, font=font, size=fsize, color=BLACK)

def bullet_box(c, x, y, w, h, title, bullets, fill, stroke, title_fill,
               title_fsize=8.5, bullet_fsize=7.8):
    """Box with coloured title bar and bullet list"""
    # outer box
    rect(c, x, y, w, h, fill=fill, stroke=stroke, radius=5)
    # title bar
    rect(c, x, y + h - 20, w, 20, fill=title_fill, stroke=stroke, radius=5)
    c.saveState()
    c.setFont("Helvetica-Bold", title_fsize)
    c.setFillColor(WHITE)
    c.drawCentredString(x + w / 2, y + h - 14, title)
    c.restoreState()
    # bullets
    c.saveState()
    c.setFont("Helvetica", bullet_fsize)
    c.setFillColor(BLACK)
    bx = x + 8
    by = y + h - 26
    for b in bullets:
        by -= (bullet_fsize + 3)
        if by < y + 4:
            break
        c.drawString(bx, by, "\u2022 " + b)
    c.restoreState()


# ════════════════════════════════════════════════════════════════════════════
# PAGE 1  — DS-TB (Drug-Susceptible) Flowchart
# ════════════════════════════════════════════════════════════════════════════
def page1(c):
    # Background gradient strip
    c.setFillColor(HexColor("#EBF3FC"))
    c.rect(0, 0, W, H, fill=1, stroke=0)

    # Header
    c.setFillColor(NAVY)
    c.rect(0, H - 52, W, 52, fill=1, stroke=0)
    c.setFillColor(YELLOW)
    c.rect(0, H - 56, W, 4, fill=1, stroke=0)

    c.setFont("Helvetica-Bold", 18)
    c.setFillColor(WHITE)
    c.drawCentredString(W / 2, H - 36, "TB MANAGEMENT FLOWCHART — INDIA (NTEP 2025)")
    c.setFont("Helvetica", 10)
    c.setFillColor(YELLOW)
    c.drawCentredString(W / 2, H - 50, "Drug-Susceptible TB (DS-TB) | National Tuberculosis Elimination Programme | Central TB Division, MoHFW")

    # Footer
    c.setFillColor(NAVY)
    c.rect(0, 0, W, 22, fill=1, stroke=0)
    c.setFont("Helvetica", 7.5)
    c.setFillColor(WHITE)
    c.drawString(10, 7, "Source: NTEP Technical & Operational Guidelines 2025 | National Guidelines for DR-TB Management March 2025 | tbcindia.mohfw.gov.in")
    c.drawRightString(W - 10, 7, "Page 1 of 2")

    # ── Layout constants ─────────────────────────────────────────────────────
    TOP = H - 70
    bw = 180   # standard box width
    bh = 38    # standard box height
    dw = 100   # diamond half-width
    dh = 32    # diamond half-height

    # COLUMN X centres
    CX = W / 2
    LEFT_COL  = 155
    RIGHT_COL = W - 155

    # ── NODE 1: Presumptive TB ───────────────────────────────────────────────
    n1x = CX - 110; n1y = TOP - bh; n1w = 220; n1h = 44
    rect(c, n1x, n1y, n1w, n1h, fill=NAVY, stroke=NAVY, radius=8, stroke_width=2)
    text_in_box(c, n1x, n1y, n1w, n1h,
                ["PRESUMPTIVE TB", "Cough \u22652 wks | fever | wt loss | night sweats"],
                font="Helvetica-Bold", size=10, color=WHITE)

    # Arrow down
    arrow(c, CX, n1y, CX, n1y - 24, color=NAVY)

    # ── NODE 2: Sputum collection ─────────────────────────────────────────
    n2x = CX - 120; n2y = n1y - 24 - 40; n2w = 240; n2h = 40
    rect(c, n2x, n2y, n2w, n2h, fill=LT_BLUE, stroke=BLUE, radius=6, stroke_width=1.5)
    text_in_box(c, n2x, n2y, n2w, n2h,
                ["SPUTUM COLLECTION",
                 "2 samples (spot + early morning)",
                 "Expectorated / induced / gastric lavage (children)"],
                font="Helvetica-Bold", size=8.5, color=NAVY)

    arrow(c, CX, n2y, CX, n2y - 20, color=NAVY)

    # ── NODE 3: Xpert MTB/RIF ───────────────────────────────────────────────
    n3x = CX - 130; n3y = n2y - 20 - 44; n3w = 260; n3h = 44
    rect(c, n3x, n3y, n3w, n3h, fill=BLUE, stroke=NAVY, radius=6, stroke_width=2)
    text_in_box(c, n3x, n3y, n3w, n3h,
                ["Xpert MTB/RIF (GeneXpert)",
                 "FIRST-LINE MOLECULAR TEST (NTEP)",
                 "Result in ~2 hours"],
                font="Helvetica-Bold", size=9, color=WHITE)

    arrow(c, CX, n3y, CX, n3y - 22, color=NAVY)

    # ── DIAMOND 1: MTB Detected? ─────────────────────────────────────────────
    d1cx = CX; d1cy = n3y - 22 - dh
    diamond(c, d1cx, d1cy, dw + 20, dh, fill=LT_YELLOW, stroke=ORANGE, stroke_width=2)
    text_in_box(c, d1cx - dw - 20, d1cy - dh, (dw + 20) * 2, dh * 2,
                ["MTB DETECTED?"],
                font="Helvetica-Bold", size=9.5, color=ORANGE)

    # YES — left branch
    arrow(c, d1cx - dw - 20, d1cy, 310, d1cy, color=GREEN, label="YES", label_color=GREEN)

    # NO — right branch
    arrow(c, d1cx + dw + 20, d1cy, W - 310, d1cy, color=RED, label="NO", label_color=RED)

    # ═══ LEFT BRANCH (MTB Detected) ════════════════════════════════════════

    # DIAMOND 2: RIF Resistant?
    d2cx = 195; d2cy = d1cy
    diamond(c, d2cx, d2cy, 88, 28, fill=LT_GREEN, stroke=GREEN, stroke_width=1.8)
    text_in_box(c, d2cx - 88, d2cy - 28, 176, 56,
                ["RIF", "Resistant?"],
                font="Helvetica-Bold", size=8.5, color=GREEN)

    # NO (RIF sensitive) → DS-TB — straight down
    ds_x = d2cx; ds_y_top = d2cy - 28
    arrow(c, d2cx, ds_y_top, d2cx, ds_y_top - 22, color=GREEN, label="NO (Sensitive)", label_color=GREEN)

    # DS-TB BOX
    ds_bx = d2cx - 110; ds_by = ds_y_top - 22 - 44; ds_bw = 220; ds_bh = 44
    rect(c, ds_bx, ds_by, ds_bw, ds_bh, fill=GREEN, stroke=GREEN, radius=7, stroke_width=2)
    text_in_box(c, ds_bx, ds_by, ds_bw, ds_bh,
                ["DS-TB", "Drug-Susceptible TB", "→ Standard Treatment"],
                font="Helvetica-Bold", size=9.5, color=WHITE)

    arrow(c, d2cx, ds_by, d2cx, ds_by - 22, color=GREEN)

    # Treatment regimen boxes
    tr_y = ds_by - 22 - 50; tr_bw = 210; tr_bh = 50
    # Intensive
    rect(c, d2cx - tr_bw - 8, tr_y, tr_bw, tr_bh, fill=LT_GREEN, stroke=GREEN, radius=5)
    text_in_box(c, d2cx - tr_bw - 8, tr_y, tr_bw, tr_bh,
                ["Intensive Phase (2 months)",
                 "H + R + Z + E  (Daily FDC)",
                 "Weight-band based dosing"],
                size=8.5, color=GREEN)

    # Continuation
    rect(c, d2cx + 8, tr_y, tr_bw, tr_bh, fill=LT_BLUE, stroke=BLUE, radius=5)
    text_in_box(c, d2cx + 8, tr_y, tr_bw, tr_bh,
                ["Continuation Phase (4 months)",
                 "H + R  (Daily FDC)",
                 "Total = 6 months"],
                size=8.5, color=BLUE)

    arrow(c, d2cx, tr_y, d2cx, tr_y - 20, color=NAVY)

    # Weight band table
    wb_y = tr_y - 20 - 72; wb_bw = 230; wb_bh = 72
    rect(c, d2cx - wb_bw / 2, wb_y, wb_bw, wb_bh, fill=GREY, stroke=NAVY, radius=4)
    c.setFont("Helvetica-Bold", 8)
    c.setFillColor(NAVY)
    c.drawCentredString(d2cx, wb_y + wb_bh - 10, "Daily FDC — Weight Band Dosing")
    c.setFont("Helvetica", 7.8)
    c.setFillColor(BLACK)
    wb_data = [
        ("25-39 kg", "2 tablets HRZE / 2 tab HR"),
        ("40-54 kg", "3 tablets HRZE / 3 tab HR"),
        ("55-69 kg", "4 tablets HRZE / 4 tab HR"),
        ("\u226570 kg", "5 tablets HRZE / 5 tab HR"),
    ]
    for i, (wt, dose) in enumerate(wb_data):
        row_y = wb_y + wb_bh - 24 - i * 14
        bg = LT_BLUE if i % 2 == 0 else WHITE
        c.setFillColor(bg)
        c.rect(d2cx - wb_bw / 2 + 2, row_y - 2, wb_bw - 4, 13, fill=1, stroke=0)
        c.setFillColor(BLACK)
        c.drawString(d2cx - wb_bw / 2 + 6, row_y + 1, wt)
        c.drawString(d2cx - 20, row_y + 1, dose)

    arrow(c, d2cx, wb_y, d2cx, wb_y - 18, color=NAVY)

    # Extensions box
    ext_y = wb_y - 18 - 52; ext_bw = 260; ext_bh = 52
    rect(c, d2cx - ext_bw / 2, ext_y, ext_bw, ext_bh, fill=LT_ORANGE, stroke=ORANGE, radius=5)
    text_in_box(c, d2cx - ext_bw / 2, ext_y, ext_bw, ext_bh,
                ["EXTENDED TREATMENT (12 months: 2HRZE/10HR)",
                 "CNS TB | Spinal TB (Pott's) | Bone & Joint TB",
                 "Severe Miliary TB"],
                size=8, color=ORANGE)

    # YES (RIF Resistant) → DR-TB → arrow downward
    dr_from_x = d2cx; dr_from_y = d2cy + 28
    arrow(c, d2cx, d2cy - 28, d2cx, d2cy - 28 - 18, color=RED, label="YES", label_color=RED)
    # small note
    rect(c, d2cx - 80, d2cy - 28 - 18 - 28, 160, 28, fill=LT_RED, stroke=RED, radius=4)
    text_in_box(c, d2cx - 80, d2cy - 28 - 18 - 28, 160, 28,
                ["DR-TB", "\u2192 See Page 2"], size=8.5, color=RED)

    # ═══ RIGHT BRANCH (MTB Not Detected) ══════════════════════════════════

    rnd_cx = W - 195
    # Clinical suspicion diamond
    d3cx = rnd_cx; d3cy = d1cy
    diamond(c, d3cx, d3cy, 95, 30, fill=LT_PURPLE, stroke=PURPLE, stroke_width=1.8)
    text_in_box(c, d3cx - 95, d3cy - 30, 190, 60,
                ["Clinical / CXR", "Suspicion?"],
                font="Helvetica-Bold", size=8.5, color=PURPLE)

    # YES → Clinical diagnosis
    arrow(c, d3cx, d3cy - 30, d3cx, d3cy - 30 - 22, color=PURPLE, label="Strong", label_color=PURPLE)
    clin_bx = d3cx - 105; clin_by = d3cy - 30 - 22 - 40; clin_bw = 210; clin_bh = 40
    rect(c, clin_bx, clin_by, clin_bw, clin_bh, fill=LT_PURPLE, stroke=PURPLE, radius=5)
    text_in_box(c, clin_bx, clin_by, clin_bw, clin_bh,
                ["Clinical/Radiological Diagnosis",
                 "CXR + Clinical Criteria",
                 "Consider EPTB workup"],
                size=8.5, color=PURPLE)

    arrow(c, d3cx, clin_by, d3cx, clin_by - 18, color=PURPLE)

    # Treat empirically
    emp_bx = d3cx - 100; emp_by = clin_by - 18 - 36; emp_bw = 200; emp_bh = 36
    rect(c, emp_bx, emp_by, emp_bw, emp_bh, fill=PURPLE, stroke=PURPLE, radius=5)
    text_in_box(c, emp_bx, emp_by, emp_bw, emp_bh,
                ["Empirical Anti-TB Treatment",
                 "2HRZE / 4HR (Clinical Diagnosis)"],
                font="Helvetica-Bold", size=8.5, color=WHITE)

    # NO → Investigate further
    arrow(c, d3cx + 95, d3cy, d3cx + 95 + 50, d3cy, color=MID_GREY, label="Low", label_color=MID_GREY)
    inv_bx = d3cx + 145; inv_by = d3cy - 20; inv_bw = 150; inv_bh = 40
    rect(c, inv_bx, inv_by, inv_bw, inv_bh, fill=GREY, stroke=MID_GREY, radius=4)
    text_in_box(c, inv_bx, inv_by, inv_bw, inv_bh,
                ["Consider Alternative Dx",
                 "Monitor / Reassess"],
                size=8, color=HexColor("#555555"))

    # ═══ EPTB SECTION ════════════════════════════════════════════════════════
    eptb_y = 90
    eptb_bx = MARGIN; eptb_bw = W - 2 * MARGIN; eptb_bh = 60
    rect(c, eptb_bx, eptb_y, eptb_bw, eptb_bh, fill=LT_TEAL, stroke=TEAL, radius=6, stroke_width=1.5)

    c.setFillColor(TEAL)
    c.rect(eptb_bx, eptb_y + eptb_bh - 20, eptb_bw, 20, fill=1, stroke=0)
    c.setFont("Helvetica-Bold", 9)
    c.setFillColor(WHITE)
    c.drawCentredString(W / 2, eptb_y + eptb_bh - 13, "EXTRAPULMONARY TB (EPTB) — Use Xpert on Relevant Specimen")

    eptb_data = [
        ("Lymph Node TB", "FNAC + ZN + Xpert | LN biopsy culture"),
        ("Pleural TB", "Pleural fluid ADA (>40) + Xpert on biopsy"),
        ("TB Meningitis", "CSF: Xpert + culture + ADA (>10)\nDexamethasone adjunct"),
        ("Spinal TB", "CT/MRI guided biopsy + Xpert\n12 months treatment"),
        ("Peritoneal TB", "Ascites ADA (>33) + laparoscopy + biopsy"),
        ("GU TB", "Urine: Xpert / culture (3 samples)"),
    ]
    col_w_e = (eptb_bw - 20) / len(eptb_data)
    for i, (site, note) in enumerate(eptb_data):
        ex = eptb_bx + 10 + i * col_w_e
        c.setFont("Helvetica-Bold", 7.5)
        c.setFillColor(TEAL)
        c.drawString(ex, eptb_y + eptb_bh - 32, site)
        c.setFont("Helvetica", 7)
        c.setFillColor(BLACK)
        for j, ln in enumerate(note.split("\n")):
            c.drawString(ex, eptb_y + eptb_bh - 44 - j * 10, ln)

    # ═══ COMMON ACTIONS FOOTER (above page footer) ═══════════════════════════
    ca_y = eptb_y - 4
    ca_bx = MARGIN; ca_bw = W - 2 * MARGIN; ca_bh = 26
    # already above footer; shift up
    ca_y = 26
    rect(c, ca_bx, ca_y, ca_bw, ca_bh, fill=NAVY, stroke=NAVY, radius=4)
    c.setFont("Helvetica-Bold", 8)
    c.setFillColor(YELLOW)
    c.drawCentredString(W / 2, ca_y + 16, "FOR ALL TB PATIENTS:")
    c.setFont("Helvetica", 7.5)
    c.setFillColor(WHITE)
    c.drawCentredString(W / 2, ca_y + 6,
        "Notify on Nikshay  \u2502  Nikshay Poshan Yojana (\u20b9500/month)  \u2502  Contact investigation + TPT (6H/3HP)  \u2502  Pyridoxine (B6) with INH  \u2502  Monthly sputum monitoring  \u2502  Adherence counselling")

    # Legend
    legend_items = [
        (NAVY,   "Diagnostic Step"),
        (GREEN,  "DS-TB Treatment"),
        (ORANGE, "Decision / Branch"),
        (RED,    "DR-TB Pathway"),
        (TEAL,   "EPTB"),
        (PURPLE, "Clinical Suspicion"),
    ]
    lx = W - 220; ly = H - 130
    c.setFont("Helvetica-Bold", 8)
    c.setFillColor(NAVY)
    c.drawString(lx, ly + 12, "LEGEND")
    for i, (col, label) in enumerate(legend_items):
        c.setFillColor(col)
        c.rect(lx, ly - 4 - i * 14, 12, 10, fill=1, stroke=0)
        c.setFillColor(BLACK)
        c.setFont("Helvetica", 7.5)
        c.drawString(lx + 16, ly - 3 - i * 14, label)

    c.showPage()


# ════════════════════════════════════════════════════════════════════════════
# PAGE 2 — DR-TB Flowchart
# ════════════════════════════════════════════════════════════════════════════
def page2(c):
    c.setFillColor(HexColor("#FFF5F0"))
    c.rect(0, 0, W, H, fill=1, stroke=0)

    # Header
    c.setFillColor(RED)
    c.rect(0, H - 52, W, 52, fill=1, stroke=0)
    c.setFillColor(YELLOW)
    c.rect(0, H - 56, W, 4, fill=1, stroke=0)

    c.setFont("Helvetica-Bold", 18)
    c.setFillColor(WHITE)
    c.drawCentredString(W / 2, H - 36, "DR-TB MANAGEMENT FLOWCHART — INDIA (NTEP 2025)")
    c.setFont("Helvetica", 10)
    c.setFillColor(YELLOW)
    c.drawCentredString(W / 2, H - 50, "Drug-Resistant TB | National Guidelines for Management of DR-TB — March 27, 2025 | MoHFW India")

    # Footer
    c.setFillColor(NAVY)
    c.rect(0, 0, W, 22, fill=1, stroke=0)
    c.setFont("Helvetica", 7.5)
    c.setFillColor(WHITE)
    c.drawString(10, 7, "Source: NTEP National Guidelines for DR-TB Management March 2025 | ZeNix trial | TB-PRACTECAL trial | tbcindia.mohfw.gov.in")
    c.drawRightString(W - 10, 7, "Page 2 of 2")

    TOP = H - 70
    CX = W / 2
    dh = 30

    # ── NODE: RR/MDR-TB Confirmed ────────────────────────────────────────────
    n1x = CX - 150; n1y = TOP - 44; n1w = 300; n1h = 44
    rect(c, n1x, n1y, n1w, n1h, fill=RED, stroke=HexColor("#8B0000"), radius=8, stroke_width=2)
    text_in_box(c, n1x, n1y, n1w, n1h,
                ["MDR-TB / RR-TB CONFIRMED",
                 "Xpert MTB/RIF: RIF Resistant",
                 "Send for LPA + Culture + Full DST"],
                font="Helvetica-Bold", size=10, color=WHITE)

    arrow(c, CX, n1y, CX, n1y - 22, color=RED, width=2)

    # ── DST Results ─────────────────────────────────────────────────────────
    dst_x = CX - 130; dst_y = n1y - 22 - 38; dst_w = 260; dst_h = 38
    rect(c, dst_x, dst_y, dst_w, dst_h, fill=LT_RED, stroke=RED, radius=5)
    text_in_box(c, dst_x, dst_y, dst_w, dst_h,
                ["AWAIT DST RESULTS",
                 "LPA: Detect H & R resistance",
                 "Culture DST: FQ, Group A/B drug susceptibility"],
                size=8.5, color=RED)

    arrow(c, CX, dst_y, CX, dst_y - 20, color=RED, width=1.8)

    # ── DIAMOND: FQ Susceptible? ──────────────────────────────────────────
    d1cx = CX; d1cy = dst_y - 20 - dh
    diamond(c, d1cx, d1cy, 105, dh, fill=LT_YELLOW, stroke=ORANGE, stroke_width=2)
    text_in_box(c, d1cx - 105, d1cy - dh, 210, dh * 2,
                ["Fluoroquinolone (FQ)", "Susceptible?"],
                font="Helvetica-Bold", size=9, color=ORANGE)

    # ══ YES (FQ Susceptible) — LEFT ══════════════════════════════════════
    arrow(c, d1cx - 105, d1cy, 195, d1cy, color=GREEN, width=1.8, label="YES", label_color=GREEN)

    # BPaLM BOX
    bpalm_cx = 170
    bpalm_bx = bpalm_cx - 155; bpalm_by = d1cy - 28 - 60; bpalm_bw = 310; bpalm_bh = 60
    arrow(c, bpalm_cx, d1cy - dh * 0, bpalm_cx, bpalm_by + bpalm_bh, color=GREEN, width=1.8)
    # shift arrow start
    arrow(c, 195, d1cy, bpalm_cx, d1cy, color=GREEN, width=1.2)
    arrow(c, bpalm_cx, d1cy, bpalm_cx, bpalm_by + bpalm_bh, color=GREEN, width=1.5)

    rect(c, bpalm_bx, bpalm_by, bpalm_bw, bpalm_bh, fill=GREEN, stroke=HexColor("#0D4D26"), radius=7, stroke_width=2)
    text_in_box(c, bpalm_bx, bpalm_by, bpalm_bw, bpalm_bh,
                ["BPaLM REGIMEN (PREFERRED)",
                 "Bedaquiline + Pretomanid + Linezolid + Moxifloxacin",
                 "Duration: 6 months (all-oral, shorter)"],
                font="Helvetica-Bold", size=9.5, color=WHITE)

    arrow(c, bpalm_cx, bpalm_by, bpalm_cx, bpalm_by - 18, color=GREEN, width=1.5)

    # BPaLM details sub-box
    bd_bx = bpalm_cx - 155; bd_by = bpalm_by - 18 - 80; bd_bw = 310; bd_bh = 80
    rect(c, bd_bx, bd_by, bd_bw, bd_bh, fill=LT_GREEN, stroke=GREEN, radius=5)
    c.setFont("Helvetica-Bold", 8.5)
    c.setFillColor(GREEN)
    c.drawCentredString(bpalm_cx, bd_by + bd_bh - 12, "BPaLM Dosing")
    c.setFont("Helvetica", 8)
    c.setFillColor(BLACK)
    bpalm_doses = [
        "Bedaquiline (Bdq): 400 mg/d \u00d7 2 wks \u2192 200 mg 3\u00d7/wk \u00d7 24 wks",
        "Pretomanid (Pa): 200 mg daily \u00d7 26 weeks",
        "Linezolid (Lzd): 600 mg daily \u00d7 26 weeks",
        "Moxifloxacin (Mfx): 400 mg daily \u00d7 26 weeks",
        "Evidence: TB-PRACTECAL trial (2022)",
    ]
    for i, d in enumerate(bpalm_doses):
        c.drawString(bd_bx + 8, bd_by + bd_bh - 26 - i * 12, "\u2022 " + d)

    # ══ NO (FQ Resistant) — RIGHT ══════════════════════════════════════
    arrow(c, d1cx + 105, d1cy, W - 190, d1cy, color=RED, width=1.8, label="NO (FQ Resistant)", label_color=RED)

    bpal_cx = W - 170
    bpal_bx = bpal_cx - 150; bpal_by = d1cy - 28 - 60; bpal_bw = 300; bpal_bh = 60
    arrow(c, W - 190, d1cy, bpal_cx, d1cy, color=RED, width=1.2)
    arrow(c, bpal_cx, d1cy, bpal_cx, bpal_by + bpal_bh, color=RED, width=1.5)

    rect(c, bpal_bx, bpal_by, bpal_bw, bpal_bh, fill=RED, stroke=HexColor("#8B0000"), radius=7, stroke_width=2)
    text_in_box(c, bpal_bx, bpal_by, bpal_bw, bpal_bh,
                ["BPaL REGIMEN",
                 "Bedaquiline + Pretomanid + Linezolid",
                 "Duration: 6 months"],
                font="Helvetica-Bold", size=9.5, color=WHITE)

    arrow(c, bpal_cx, bpal_by, bpal_cx, bpal_by - 18, color=RED, width=1.5)

    bd2_bx = bpal_cx - 150; bd2_by = bpal_by - 18 - 80; bd2_bw = 300; bd2_bh = 80
    rect(c, bd2_bx, bd2_by, bd2_bw, bd2_bh, fill=LT_RED, stroke=RED, radius=5)
    c.setFont("Helvetica-Bold", 8.5)
    c.setFillColor(RED)
    c.drawCentredString(bpal_cx, bd2_by + bd2_bh - 12, "BPaL Dosing (ZeNix Trial)")
    c.setFont("Helvetica", 8)
    c.setFillColor(BLACK)
    bpal_doses = [
        "Bedaquiline (Bdq): 400mg/d \u00d7 2wks \u2192 200mg 3\u00d7/wk \u00d7 24wks",
        "Pretomanid (Pa): 200 mg daily \u00d7 26 weeks",
        "Linezolid (Lzd): 600 mg daily \u00d7 26 weeks",
        "Note: 600mg Lzd preferred (less toxic vs 1200mg)",
        "Use when FQ resistance confirmed or XDR-TB",
    ]
    for i, d in enumerate(bpal_doses):
        c.drawString(bd2_bx + 8, bd2_by + bd2_bh - 26 - i * 12, "\u2022 " + d)

    # ══ CENTRE: 9-11 month option ════════════════════════════════════════
    alt_bx = CX - 130; alt_by = bd_by - 18; alt_bw = 260; alt_bh = 58
    arrow(c, CX, d1cy - dh, CX, alt_by + alt_bh, color=ORANGE, width=1.2)
    rect(c, alt_bx, alt_by, alt_bw, alt_bh, fill=LT_ORANGE, stroke=ORANGE, radius=5, stroke_width=1.5)
    c.setFont("Helvetica-Bold", 8.5)
    c.setFillColor(ORANGE)
    c.drawCentredString(CX, alt_by + alt_bh - 12, "SHORTER REGIMEN (9-11 months) — STREAM")
    c.setFont("Helvetica", 8)
    c.setFillColor(BLACK)
    alt_lines = [
        "Intensive (4-6m): Bdq + Lfx/Mfx + Cfz + Z + E + H(HD) + Eto",
        "Continuation (5m): Lfx/Mfx + Cfz + Z + E",
        "Use when BPaLM/BPaL not feasible | FQ-susceptible MDR-TB",
    ]
    for i, ln in enumerate(alt_lines):
        c.drawString(alt_bx + 8, alt_by + alt_bh - 26 - i * 12, "\u2022 " + ln)

    # ══ MONITORING BOX ═══════════════════════════════════════════════════
    mon_y = min(bd_by, bd2_by) - 30
    mon_bx = MARGIN; mon_bw = W - 2 * MARGIN; mon_bh = 68
    mon_by = mon_y - mon_bh
    rect(c, mon_bx, mon_by, mon_bw, mon_bh, fill=LT_BLUE, stroke=BLUE, radius=5, stroke_width=1.5)
    c.setFillColor(BLUE)
    c.rect(mon_bx, mon_by + mon_bh - 20, mon_bw, 20, fill=1, stroke=0)
    c.setFont("Helvetica-Bold", 9)
    c.setFillColor(WHITE)
    c.drawCentredString(W / 2, mon_by + mon_bh - 13, "MANDATORY MONITORING DURING DR-TB TREATMENT")
    mon_cols = [
        ("Sputum smear + culture", "Monthly (intensive) → 2-monthly (continuation)"),
        ("ECG (QTc)", "Baseline → Monthly (Bdq, Dlm, Cfz, Mfx)"),
        ("LFT", "Baseline → Monthly (Lzd, Eto, PZA)"),
        ("CBC", "Monthly (Linezolid: myelosuppression)"),
        ("Peripheral neuropathy", "Monthly (Lzd, Cycloserine)"),
        ("Visual acuity", "Baseline + 6-monthly (EMB, Lzd)"),
        ("TSH", "Baseline + 6-monthly (Eto + PAS)"),
        ("Renal function", "Monthly if aminoglycoside used"),
    ]
    col_w_m = (mon_bw - 20) / len(mon_cols)
    for i, (test, freq) in enumerate(mon_cols):
        mx = mon_bx + 10 + i * col_w_m
        c.setFont("Helvetica-Bold", 7.5)
        c.setFillColor(BLUE)
        c.drawString(mx, mon_by + mon_bh - 32, test)
        c.setFont("Helvetica", 7)
        c.setFillColor(BLACK)
        c.drawString(mx, mon_by + mon_bh - 44, freq)

    # ══ DRUG GROUPS ══════════════════════════════════════════════════════
    dg_y = mon_by - 14
    dg_bx = MARGIN; dg_bw = W - 2 * MARGIN; dg_bh = 70
    dg_by = dg_y - dg_bh
    rect(c, dg_bx, dg_by, dg_bw, dg_bh, fill=GREY, stroke=NAVY, radius=5)
    c.setFillColor(NAVY)
    c.rect(dg_bx, dg_by + dg_bh - 20, dg_bw, 20, fill=1, stroke=0)
    c.setFont("Helvetica-Bold", 9)
    c.setFillColor(WHITE)
    c.drawCentredString(W / 2, dg_by + dg_bh - 13, "WHO / NTEP DRUG GROUPS FOR MDR-TB TREATMENT")

    grp_data = [
        ("GROUP A\n(Use ALL 3)", "Levofloxacin / Moxifloxacin\nBedaquiline (Bdq)\nLinezolid (Lzd)", GREEN, LT_GREEN),
        ("GROUP B\n(Add 1-2)", "Clofazimine (Cfz)\nCycloserine (Cs) / Terizidone", BLUE, LT_BLUE),
        ("GROUP C\n(Add to complete)", "Ethambutol, Delamanid, PZA\nImipenem-cilastatin, Amikacin\nEthionamide/Prothionamide, PAS", ORANGE, LT_ORANGE),
        ("DELAMANID\n(Add-on)", "100mg BD \u00d7 24 weeks\nFor MDR+FQ resist, XDR-TB\nQTc monitoring mandatory", PURPLE, LT_PURPLE),
        ("REGIMEN DURATIONS", "BPaLM: 6 months\nBPaL: 6 months\nShorter: 9-11 months\nLonger: 18-20 months", NAVY, HexColor("#D6E8F8")),
    ]
    grp_cw = (dg_bw - 20) / len(grp_data)
    for i, (gname, gdrugs, gcol, gbg) in enumerate(grp_data):
        gx = dg_bx + 10 + i * grp_cw
        rect(c, gx, dg_by + 4, grp_cw - 4, dg_bh - 28, fill=gbg, stroke=gcol, radius=4)
        c.setFillColor(gcol)
        c.rect(gx, dg_by + dg_bh - 28, grp_cw - 4, 12, fill=1, stroke=0)
        c.setFont("Helvetica-Bold", 7.5)
        c.setFillColor(WHITE)
        c.drawCentredString(gx + (grp_cw - 4) / 2, dg_by + dg_bh - 21, gname.split("\n")[0])
        c.setFont("Helvetica", 7)
        c.setFillColor(BLACK)
        for j, ln in enumerate(gdrugs.split("\n")):
            c.drawString(gx + 4, dg_by + dg_bh - 38 - j * 11, ln)

    # ══ XDR/Pre-XDR note ═══════════════════════════════════════════════════
    xdr_by = dg_by - 36
    rect(c, MARGIN, xdr_by, W - 2 * MARGIN, 30, fill=LT_RED, stroke=RED, radius=4)
    c.setFont("Helvetica-Bold", 8.5)
    c.setFillColor(RED)
    c.drawString(MARGIN + 10, xdr_by + 18, "Pre-XDR / XDR-TB:")
    c.setFont("Helvetica", 8)
    c.setFillColor(BLACK)
    c.drawString(MARGIN + 110, xdr_by + 18,
        "Individualized regimen \u2265 5 active drugs | Use all available Group A + B + C drugs | Duration 18-20 months | Refer to DR-TB Centre")
    c.drawString(MARGIN + 10, xdr_by + 6,
        "XDR-TB Definition (WHO 2021): MDR/RR-TB + ANY FQ resistance + Bedaquiline OR Linezolid resistance | QTc monitoring: avoid Bdq+Dlm+Mfx without rigorous ECG monitoring")

    # ══ NIKSHAY / SUPPORT FOOTER ═══════════════════════════════════════════
    nik_by = 26
    rect(c, MARGIN, nik_by, W - 2 * MARGIN, 26, fill=NAVY, stroke=NAVY, radius=4)
    c.setFont("Helvetica-Bold", 8)
    c.setFillColor(YELLOW)
    c.drawString(MARGIN + 10, nik_by + 16, "ALL DR-TB PATIENTS:")
    c.setFont("Helvetica", 7.5)
    c.setFillColor(WHITE)
    c.drawString(MARGIN + 130, nik_by + 16,
        "Notify on Nikshay  \u2502  Nikshay Poshan Yojana (\u20b9500/month)  \u2502  Nikshay Mitra support  \u2502  Counselling on QTc-prolonging drugs  \u2502  Refer to DR-TB Centre")
    c.setFont("Helvetica", 7.5)
    c.setFillColor(YELLOW)
    c.drawString(MARGIN + 10, nik_by + 5, "TPT for contacts:")
    c.setFont("Helvetica", 7.5)
    c.setFillColor(WHITE)
    c.drawString(MARGIN + 80, nik_by + 5,
        "Household contacts of DR-TB: do NOT give standard TPT; refer for specialist opinion | Screen all contacts with Xpert")

    c.showPage()


# ════════════════════════════════════════════════════════════════════════════
# MAIN
# ════════════════════════════════════════════════════════════════════════════
out = "/tmp/workspace/tb-ppt/TB_Management_Flowchart_NTEP_India_2025.pdf"
c = make_canvas(out)
page1(c)
page2(c)
c.save()
print(f"Saved: {out}")