const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.title = "Type 2 Diabetes Mellitus – ADA Standards of Care 2026";
pres.author = "ADA Standards of Care 2026";

// ── COLOR PALETTE ─────────────────────────────────────────────────────────────
const C = {
  navy:    "1B3A6B",   // deep navy – dominant (titles, accents)
  teal:    "0B7A75",   // rich teal – section banners
  sky:     "3D9BE9",   // sky blue – highlights
  mint:    "D6F0EE",   // pale mint – content bg
  white:   "FFFFFF",
  offwhite:"F5F8FC",
  gold:    "F4A742",   // warm amber – callouts
  lightgold:"FEF3E2",
  text:    "1A1A2E",   // near-black text
  muted:   "5A6A82",   // secondary text
  red:     "C0392B",   // contraindication red
  lightred:"FDECEA",
  green:   "1A7A4A",
  lightgreen:"E8F5EE",
};

// ── HELPER FUNCTIONS ──────────────────────────────────────────────────────────

function addDarkSlide(slide, titleText, subtitleText) {
  // Full dark navy background
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  // Teal accent bar bottom
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 6.8, w: 13.3, h: 0.7, fill: { color: C.teal } });
  // ADA badge top-right
  slide.addShape(pres.ShapeType.rect, { x: 11.5, y: 0.3, w: 1.5, h: 0.5, fill: { color: C.gold }, line: { color: C.gold } });
  slide.addText("ADA 2026", { x: 11.5, y: 0.3, w: 1.5, h: 0.5, fontSize: 10, bold: true, color: C.navy, align: "center", valign: "middle" });

  slide.addText(titleText, {
    x: 0.7, y: 1.8, w: 11.9, h: 1.5,
    fontSize: 46, bold: true, color: C.white, align: "center",
    fontFace: "Calibri", charSpacing: 1,
  });
  if (subtitleText) {
    slide.addText(subtitleText, {
      x: 0.7, y: 3.5, w: 11.9, h: 0.8,
      fontSize: 22, color: C.gold, align: "center", fontFace: "Calibri", italic: true,
    });
  }
  slide.addText("Standards of Care in Diabetes — 2026  |  Diabetes Care 49(Suppl. 1)", {
    x: 0, y: 7.05, w: 13.3, h: 0.35,
    fontSize: 11, color: C.white, align: "center", fontFace: "Calibri",
  });
}

function addSectionBanner(slide, sectionLabel, titleText, bgColor) {
  bgColor = bgColor || C.offwhite;
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: bgColor } });
  // top bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 1.0, fill: { color: C.navy } });
  // left accent
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });
  // bottom bar
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 7.1, w: 13.3, h: 0.4, fill: { color: C.teal } });

  slide.addText("ADA 2026", { x: 11.7, y: 0.1, w: 1.4, h: 0.4, fontSize: 9, bold: true, color: C.gold, align: "right", fontFace: "Calibri" });

  if (sectionLabel) {
    slide.addShape(pres.ShapeType.rect, { x: 0.5, y: 0.12, w: 1.8, h: 0.38,
      fill: { color: C.gold }, line: { color: C.gold } });
    slide.addText(sectionLabel, { x: 0.5, y: 0.12, w: 1.8, h: 0.38,
      fontSize: 11, bold: true, color: C.navy, align: "center", valign: "middle", fontFace: "Calibri" });
  }

  slide.addText(titleText, {
    x: 0.45, y: 0.12, w: 11.0, h: 0.76,
    fontSize: 28, bold: true, color: C.white, fontFace: "Calibri",
    margin: 0, charSpacing: 0.5,
    ...(sectionLabel ? { x: 2.5 } : {}),
  });
}

function addBullets(slide, items, x, y, w, h, opts) {
  opts = opts || {};
  const fontSize = opts.fontSize || 14;
  const color = opts.color || C.text;
  const arr = items.map((t, i) => ({
    text: t,
    options: {
      bullet: opts.noBullet ? false : { code: "25CF", color: opts.bulletColor || C.teal },
      color: color, fontSize: fontSize, fontFace: "Calibri",
      breakLine: i < items.length - 1,
      paraSpaceBefore: 4,
    }
  }));
  slide.addText(arr, { x, y, w, h, valign: "top", margin: 4 });
}

function addInfoBox(slide, title, content, x, y, w, h, bgColor, titleColor) {
  bgColor = bgColor || C.mint;
  titleColor = titleColor || C.navy;
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill: { color: bgColor }, line: { color: C.navy, width: 0.5 }, shadow: { type: "outer", blur: 4, offset: 2, angle: 45, color: "888888", opacity: 0.2 } });
  // title bar
  slide.addShape(pres.ShapeType.rect, { x, y, w, h: 0.45, fill: { color: titleColor }, line: { color: titleColor } });
  slide.addText(title, { x: x + 0.1, y, w: w - 0.2, h: 0.45,
    fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  if (typeof content === "string") {
    slide.addText(content, { x: x + 0.12, y: y + 0.48, w: w - 0.24, h: h - 0.56,
      fontSize: 12, color: C.text, fontFace: "Calibri", valign: "top", wrap: true });
  } else if (Array.isArray(content)) {
    addBullets(slide, content, x + 0.12, y + 0.48, w - 0.24, h - 0.56, { fontSize: 11, bulletColor: titleColor });
  }
}

function addFlowStep(slide, num, text, x, y, w, h, color) {
  color = color || C.teal;
  slide.addShape(pres.ShapeType.roundRect, { x, y, w, h, fill: { color }, line: { color: C.navy, width: 0.5 }, rectRadius: 0.08 });
  slide.addText([
    { text: num + "\n", options: { fontSize: 18, bold: true, color: C.white, fontFace: "Calibri" } },
    { text, options: { fontSize: 11, color: C.white, fontFace: "Calibri" } },
  ], { x, y, w, h, align: "center", valign: "middle" });
}

function addArrow(slide, x, y, w, h, vertical) {
  if (vertical) {
    slide.addShape(pres.ShapeType.downArrow, { x, y, w, h, fill: { color: C.gold }, line: { color: C.gold } });
  } else {
    slide.addShape(pres.ShapeType.rightArrow, { x, y, w, h, fill: { color: C.gold }, line: { color: C.gold } });
  }
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 – TITLE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addDarkSlide(s, "TYPE 2 DIABETES MELLITUS", "A Comprehensive Clinical Review · ADA Standards of Care 2026");
  // decorative circles
  s.addShape(pres.ShapeType.ellipse, { x: -0.8, y: -0.8, w: 3.5, h: 3.5, fill: { color: C.teal, transparency: 80 }, line: { color: C.teal, transparency: 80 } });
  s.addShape(pres.ShapeType.ellipse, { x: 11, y: 5, w: 3, h: 3, fill: { color: C.sky, transparency: 85 }, line: { color: C.sky, transparency: 85 } });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 – OVERVIEW: WHAT IS T2DM?
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "OVERVIEW", "What Is Type 2 Diabetes Mellitus?");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  // Key definition box
  addInfoBox(s,
    "Definition (ADA 2026)",
    "Type 2 diabetes accounts for 90–95% of all diabetes cases. It encompasses individuals who have a relative (rather than absolute) insulin deficiency in association with insulin resistance — decreased biological responses to insulin.\n\nPathophysiology: Non-autoimmune progressive loss of adequate β-cell insulin secretion, frequently on the background of insulin resistance.",
    0.4, 1.2, 5.8, 2.2, C.mint, C.navy
  );

  // Global burden
  addInfoBox(s,
    "Global & US Burden",
    "• 537 million adults living with diabetes worldwide (IDF 2021)\n• T2DM prevalence rising dramatically in children & adolescents\n• Often undiagnosed for years — hyperglycemia is gradual\n• Undiagnosed individuals at high risk of macro- and microvascular complications",
    0.4, 3.55, 5.8, 2.2, C.lightgold, C.gold
  );

  // Pathophysiology pillars
  s.addShape(pres.ShapeType.rect, { x: 6.5, y: 1.15, w: 6.5, h: 5.75, fill: { color: C.white }, line: { color: C.navy, width: 0.5 } });
  s.addText("Key Pathophysiologic Features", { x: 6.5, y: 1.15, w: 6.5, h: 0.45, fontSize: 14, bold: true, color: C.white, fontFace: "Calibri",
    fill: { color: C.navy }, align: "center", valign: "middle" });

  const features = [
    ["🔴", "Insulin Resistance", "Skeletal muscle, liver, adipose tissue fail to respond normally to insulin signals"],
    ["🔵", "β-cell Dysfunction", "Progressive loss of insulin secretory capacity; genetic + epigenetic + metabolic stress"],
    ["🟡", "Compensatory Hyperinsulinemia", "Initially elevated insulin, then failing compensation → hyperglycemia"],
    ["🟢", "Glucotoxicity / Lipotoxicity", "Chronic hyperglycemia & free fatty acids worsen β-cell function"],
    ["🟣", "Incretin Defect", "Reduced GLP-1 / GIP effect; impaired postprandial insulin secretion"],
  ];

  features.forEach((f, i) => {
    const fy = 1.75 + i * 0.95;
    s.addShape(pres.ShapeType.rect, { x: 6.6, y: fy, w: 0.5, h: 0.7, fill: { color: i % 2 === 0 ? C.teal : C.sky }, line: { color: "FFFFFF" } });
    s.addText(f[1], { x: 7.2, y: fy, w: 2.5, h: 0.35, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri" });
    s.addText(f[2], { x: 7.2, y: fy + 0.35, w: 5.6, h: 0.35, fontSize: 10, color: C.muted, fontFace: "Calibri" });
  });

  s.addText("ADA 2026 · Sections 2 & 9", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 – CLASSIFICATION
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "CLASSIFICATION", "ADA 2026 Classification of Diabetes Mellitus");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  const types = [
    { label: "Type 1 DM", desc: "Autoimmune β-cell destruction → absolute insulin deficiency\n(incl. LADA)", color: C.navy },
    { label: "Type 2 DM ★", desc: "Non-autoimmune progressive loss of β-cell secretion + insulin resistance\n90–95% of all cases", color: C.teal },
    { label: "Gestational DM", desc: "Diagnosed in 2nd/3rd trimester; not clearly overt DM prior to gestation", color: C.sky },
    { label: "Other Specific Types", desc: "Monogenic (MODY, neonatal DM), pancreatic disease (Type 3c), drug-induced, post-transplant (PTDM)", color: C.muted },
  ];

  types.forEach((t, i) => {
    const bx = 0.4 + (i % 2) * 6.4;
    const by = 1.3 + Math.floor(i / 2) * 2.5;
    s.addShape(pres.ShapeType.rect, { x: bx, y: by, w: 6.1, h: 2.2,
      fill: { color: C.white }, line: { color: t.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x: bx, y: by, w: 6.1, h: 0.5, fill: { color: t.color }, line: { color: t.color } });
    s.addText(t.label, { x: bx + 0.1, y: by, w: 5.9, h: 0.5, fontSize: 15, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    s.addText(t.desc, { x: bx + 0.15, y: by + 0.55, w: 5.8, h: 1.55, fontSize: 12, color: C.text, fontFace: "Calibri", valign: "top", wrap: true });
  });

  // T2DM features callout
  s.addShape(pres.ShapeType.rect, { x: 0.4, y: 6.0, w: 12.5, h: 0.9,
    fill: { color: C.lightgold }, line: { color: C.gold, width: 0.5 } });
  s.addText("★ T2DM Note: Heterogeneous disease — may not be classified as T1 or T2 at diagnosis. AABBCC tool: Age (<35 consider T1), Autoimmunity, Body habitus (BMI<25), Background (family Hx), Control (inability to achieve goals on non-insulin), Comorbidities.",
    { x: 0.55, y: 6.05, w: 12.25, h: 0.8, fontSize: 10, color: C.text, fontFace: "Calibri", valign: "middle" });

  s.addText("ADA 2026 · Section 2 (S27–S49)", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 – DIAGNOSTIC CRITERIA + FLOWCHART
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "DIAGNOSIS", "Diagnostic Criteria & Screening Flowchart");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  // Left: Diagnostic criteria table
  const criRows = [
    ["Test", "Diabetes", "Prediabetes"],
    ["A1C", "≥ 6.5% (≥48 mmol/mol)", "5.7–6.4% (39–47)"],
    ["FPG", "≥ 126 mg/dL (≥7.0 mmol/L)\nFasting ≥ 8 hrs", "100–125 mg/dL (5.6–6.9) – IFG"],
    ["2-h PG (75g OGTT)", "≥ 200 mg/dL (≥11.1 mmol/L)", "140–199 mg/dL (7.8–11.0) – IGT"],
    ["Random PG + Sx", "≥ 200 mg/dL with classic Sx\nor hyperglycemic crisis", "—"],
  ];

  let ty = 1.25;
  criRows.forEach((row, i) => {
    const bg = i === 0 ? C.navy : (i % 2 === 0 ? C.white : C.mint);
    const tc = i === 0 ? C.white : C.text;
    const bold = i === 0;
    [row[0], row[1], row[2]].forEach((cell, ci) => {
      const cw = [2.0, 3.0, 3.0][ci];
      const cx = 0.4 + [0, 2.0, 5.0][ci];
      s.addShape(pres.ShapeType.rect, { x: cx, y: ty, w: cw, h: 0.5, fill: { color: bg }, line: { color: C.navy, width: 0.3 } });
      s.addText(cell, { x: cx + 0.05, y: ty, w: cw - 0.1, h: 0.5, fontSize: i === 0 ? 12 : 10, bold, color: tc, fontFace: "Calibri", valign: "middle" });
    });
    ty += 0.5;
  });

  s.addText("* Confirmation: 2 abnormal results from same or different tests (unless classic Sx + random PG ≥200)",
    { x: 0.4, y: 3.95, w: 7.8, h: 0.35, fontSize: 9, color: C.muted, fontFace: "Calibri", italic: true });

  // Right: Screening flowchart
  const fx = 8.5;
  s.addText("SCREENING FLOWCHART — Who to Test?", { x: fx, y: 1.15, w: 4.6, h: 0.4, fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri" });

  // Flow steps
  const steps = [
    { y: 1.65, color: C.navy, text: "Asymptomatic Adult" },
    { y: 2.35, color: C.teal, text: "Any age + Overweight/Obese\n(BMI≥25 or ≥23 Asian)\n+ ≥1 risk factor (Table 2.5)" },
    { y: 3.2, color: C.sky,  text: "OR: ALL adults ≥ 35 yrs\n(regardless of weight)" },
    { y: 4.05, color: C.teal, text: "Screen: FPG / A1C / 2-h OGTT" },
    { y: 4.9, color: C.navy, text: "Normal → Repeat every 3 yrs\n(or sooner if risk ↑)" },
  ];

  steps.forEach((step, i) => {
    s.addShape(pres.ShapeType.roundRect, { x: fx, y: step.y, w: 4.6, h: 0.6,
      fill: { color: step.color }, line: { color: C.navy, width: 0.3 }, rectRadius: 0.06 });
    s.addText(step.text, { x: fx + 0.08, y: step.y, w: 4.44, h: 0.6,
      fontSize: 10, color: C.white, fontFace: "Calibri", valign: "middle", bold: i === 0 });
    if (i < steps.length - 1) {
      s.addShape(pres.ShapeType.downArrow, { x: fx + 1.8, y: step.y + 0.6, w: 1.0, h: 0.3,
        fill: { color: C.gold }, line: { color: C.gold } });
    }
  });

  // Risk factors
  addInfoBox(s, "Key Risk Factors (Table 2.5)",
    ["First-degree relative with DM", "High-risk race/ethnicity (AA, Latino, Native American, Asian)",
     "Hx of CVD, HTN (≥130/80 mmHg)", "HDL <35 mg/dL or TG >250 mg/dL",
     "PCOS, physical inactivity", "Acanthosis nigricans, MASLD, severe obesity",
     "Prior GDM / prediabetes", "HIV, steroid use, antipsychotics, statins"],
    0.4, 4.35, 7.9, 2.4, C.lightgold, C.gold
  );

  s.addText("ADA 2026 · Section 2 (S27–S49)", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 – LABS & MONITORING
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "LABS", "Laboratory Evaluation & Glycemic Monitoring");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  // Initial labs
  addInfoBox(s, "Initial Evaluation Labs",
    ["A1C (NGSP-certified lab)", "FPG or 2-h OGTT (75g)", "Fasting lipid panel (LDL, HDL, TG, TC)",
     "Serum creatinine + eGFR", "Urine albumin-to-creatinine ratio (UACR)",
     "Liver function tests (ALT/AST)", "TSH (if indicated)", "Vitamin B12 (if on metformin ≥4 yrs)",
     "Blood pressure measurement"],
    0.4, 1.2, 4.0, 4.2, C.mint, C.navy
  );

  // Glycemic targets table
  s.addShape(pres.ShapeType.rect, { x: 4.7, y: 1.15, w: 8.3, h: 0.5, fill: { color: C.navy }, line: { color: C.navy } });
  s.addText("ADA 2026 Glycemic Goals (Section 6)", { x: 4.8, y: 1.15, w: 8.1, h: 0.5,
    fontSize: 14, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });

  const gRows = [
    ["Measure", "Standard Target", "Less Stringent (frail/elderly/high risk)"],
    ["A1C", "< 7.0% (<53 mmol/mol)", "< 8.0% in selected patients"],
    ["Pre-meal glucose (BGM)", "80–130 mg/dL (4.4–7.2 mmol/L)", "—"],
    ["Peak post-meal (1–2h)", "< 180 mg/dL (<10.0 mmol/L)", "—"],
    ["Time in Range (CGM) 70–180", "> 70% of time", "> 50% (older/high-risk)"],
    ["Time Below Range <70", "< 4% (< 1% critical <54)", "—"],
    ["GMI (CGM estimate)", "Correlates to A1C target", "—"],
  ];

  gRows.forEach((row, i) => {
    const gy = 1.75 + i * 0.55;
    const bg = i === 0 ? C.teal : (i % 2 === 0 ? C.white : C.mint);
    const tc = i === 0 ? C.white : C.text;
    [row[0], row[1], row[2]].forEach((cell, ci) => {
      const cw = [2.5, 2.8, 2.8][ci];
      const cx = 4.7 + [0, 2.55, 5.4][ci];
      s.addShape(pres.ShapeType.rect, { x: cx, y: gy, w: cw, h: 0.5, fill: { color: bg }, line: { color: C.navy, width: 0.3 } });
      s.addText(cell, { x: cx + 0.05, y: gy + 0.02, w: cw - 0.1, h: 0.46,
        fontSize: i === 0 ? 11 : 10, bold: i === 0, color: tc, fontFace: "Calibri", valign: "middle" });
    });
  });

  // CGM vs BGM note
  addInfoBox(s, "CGM vs BGM",
    "• CGM preferred when available — improves TIR, reduces hypoglycemia\n• Assess glycemic status ≥2x/year (more often if not at goal or medication changes)\n• A1C and CGM metrics are complementary — both recommended (Rec 6.1)\n• Fructosamine or CGM when A1C unreliable (hemoglobinopathy, hemolysis, CKD, pregnancy)",
    4.7, 5.45, 8.3, 1.3, C.lightgold, C.gold
  );

  // Monitoring frequency
  addInfoBox(s, "Follow-up Monitoring Frequency",
    "• A1C: every 3 months if not at goal; every 6 months if stable at goal\n• Lipids: annually; UACR + eGFR: annually; BP: every visit",
    0.4, 5.5, 4.0, 1.25, C.lightgreen, C.green
  );

  s.addText("ADA 2026 · Sections 4 & 6 (S61–S149)", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 – NON-PHARMACOLOGIC TREATMENT
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "NON-PHARM Tx", "Non-Pharmacologic Treatment & Lifestyle Management");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  addInfoBox(s, "Medical Nutrition Therapy (MNT)",
    ["Reduce total calorie intake to achieve 5–10% weight loss (goal ≥5% to improve glycemia)",
     "No single optimal eating pattern — Mediterranean, DASH, low-carb, plant-based all supported",
     "Limit refined carbohydrates, added sugars, ultra-processed foods",
     "Increase dietary fiber (vegetables, legumes, whole grains)",
     "Reduce sodium to <2300 mg/day; limit alcohol",
     "Carbohydrate counting or plate method for meal planning",
     "Referral to registered dietitian for individualized MNT"],
    0.4, 1.2, 6.1, 3.2, C.mint, C.navy
  );

  addInfoBox(s, "Physical Activity",
    ["≥150 min/week moderate-intensity aerobic activity (e.g., brisk walk, cycling)",
     "Resistance training ≥2 days/week (improves insulin sensitivity)",
     "Reduce prolonged sedentary time — break sitting every 30 min",
     "Pre-exercise glucose check if on insulin/sulfonylurea",
     "Benefits: A1C ↓ ~0.5–1%, weight loss, BP ↓, lipids ↑"],
    0.4, 4.55, 6.1, 2.15, C.lightgreen, C.green
  );

  addInfoBox(s, "Diabetes Self-Management Education & Support (DSMES)",
    ["Recommended at: diagnosis, annually, when complicating factors arise, care transitions",
     "Evidence-based structured program (ADA-recognized or CDC-recognized DPP)",
     "Include: self-monitoring, medication management, foot care, sick-day rules, hypoglycemia management",
     "Address social determinants of health (SDOH)"],
    6.75, 1.2, 6.2, 2.3, C.mint, C.teal
  );

  addInfoBox(s, "Weight Management",
    ["5–10% weight loss → clinically meaningful glycemic improvement",
     "≥15% weight loss may achieve diabetes remission (DiRECT trial)",
     "Intensive lifestyle intervention (ILI) + VLCD supported",
     "Metabolic/bariatric surgery: consider if BMI ≥40 (or ≥35 with comorbidities); can achieve remission",
     "GLP-1 RA / dual GIP-GLP1 RA as pharmacologic weight management adjuncts"],
    6.75, 3.65, 6.2, 2.55, C.lightgold, C.gold
  );

  s.addText("ADA 2026 · Sections 5 & 8", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 – PHARMACOLOGIC TREATMENT OVERVIEW
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "PHARM Tx", "Pharmacologic Treatment — ADA 2026 Algorithm");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  // Title note
  s.addText("Start pharmacotherapy at diagnosis — do not delay. GLP-1 based therapy is preferred over insulin unless A1C >10% or glucose ≥300 mg/dL. (Rec 9.21)",
    { x: 0.4, y: 1.1, w: 12.8, h: 0.45, fontSize: 11, italic: true, color: C.navy, fontFace: "Calibri" });

  // Algorithm boxes
  const algSteps = [
    { title: "Step 1: All T2DM at Diagnosis", items: ["Metformin (unless contraindicated)", "Lifestyle modification (MNT + PA)", "DSMES referral"], color: C.navy },
    { title: "Step 2: Add if A1C not at goal\n(Comorbidity-driven choice)", items: ["ASCVD/HF/CKD → SGLT2i or GLP-1 RA (proven CV/renal benefit)", "Need weight loss → GLP-1 RA or dual GIP/GLP-1 RA (tirzepatide)", "Minimize hypoglycemia → DPP-4i, GLP-1 RA, SGLT2i", "Cost concern → SU, TZD, NPH insulin"], color: C.teal },
    { title: "Step 3: If A1C >10% or Glucose\n≥300 mg/dL or Symptomatic", items: ["Initiate insulin (basal preferred)", "GLP-1 RA + insulin combination preferred over insulin alone", "Reassess need for SU/meglitinide when adding insulin"], color: C.sky },
  ];

  algSteps.forEach((step, i) => {
    const bx = 0.4 + i * 4.25;
    s.addShape(pres.ShapeType.rect, { x: bx, y: 1.65, w: 4.05, h: 5.1,
      fill: { color: C.white }, line: { color: step.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x: bx, y: 1.65, w: 4.05, h: 0.7, fill: { color: step.color }, line: { color: step.color } });
    s.addText(step.title, { x: bx + 0.08, y: 1.65, w: 3.9, h: 0.7, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });

    step.items.forEach((item, j) => {
      const iy = 2.45 + j * 0.75;
      s.addShape(pres.ShapeType.rect, { x: bx + 0.15, y: iy, w: 3.75, h: 0.65,
        fill: { color: i % 2 === 0 ? C.mint : C.lightgold }, line: { color: step.color, width: 0.3 } });
      s.addText(item, { x: bx + 0.25, y: iy + 0.04, w: 3.55, h: 0.57, fontSize: 10, color: C.text, fontFace: "Calibri", valign: "middle", wrap: true });
    });

    if (i < 2) {
      s.addShape(pres.ShapeType.rightArrow, { x: bx + 4.05, y: 3.5, w: 0.25, h: 0.4,
        fill: { color: C.gold }, line: { color: C.gold } });
    }
  });

  s.addText("ADA 2026 · Section 9 (S183–S215)  |  Recs 9.15–9.23", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 – DRUG CLASSES (FEATURES TABLE)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "MEDICATIONS", "Glucose-Lowering Drug Classes — Key Features (ADA 2026 Table 9.2)");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  const headers = ["Drug Class", "Efficacy", "Hypo?", "Weight", "CV", "Kidney", "Key Adverse Effects"];
  const rows = [
    ["Metformin", "High", "No", "Neutral", "Potential benefit", "Neutral", "GI (nausea/diarrhea), B12 ↓; CI: eGFR <30"],
    ["SGLT2i\n(empa, cana, dapa)", "Intermediate–High", "No", "Loss", "Benefit MACE/HF", "Benefit CKD", "UTI, genital mycosis, DKA (rare), Fournier's"],
    ["GLP-1 RA\n(sema, lira, dula)", "High–Very High", "No", "Loss (mod–high)", "Benefit MACE", "Benefit albuminuria", "Nausea/vomiting, pancreatitis (rare), thyroid C-cell (rodents)"],
    ["Dual GIP/GLP-1 RA\n(tirzepatide)", "Very High", "No", "Very High Loss", "Under investigation", "Potential benefit", "GI effects; same precautions as GLP-1 RA"],
    ["DPP-4i\n(sitagliptin, etc.)", "Moderate", "No", "Neutral", "Neutral", "Neutral", "Pancreatitis (rare), HHF risk (saxagliptin/alogliptin)"],
    ["Sulfonylureas\n(glipizide, glimepiride)", "High", "YES ⚠", "Gain", "Neutral", "Neutral", "Hypoglycemia, weight gain; avoid with CKD"],
    ["TZD (pioglitazone)", "High", "No", "Gain", "Benefit (pio)", "Neutral", "Fluid retention, HF risk, fractures, bladder CA (pio)"],
    ["Insulin (basal/bolus)", "Highest", "YES ⚠", "Gain", "Neutral", "Neutral", "Hypoglycemia, weight gain, injection site reactions"],
  ];

  const colWidths = [2.0, 1.1, 0.7, 0.9, 1.35, 1.2, 5.75];
  const colX = [0.25, 2.3, 3.45, 4.2, 5.15, 6.55, 7.8];

  // Header row
  headers.forEach((h, ci) => {
    s.addShape(pres.ShapeType.rect, { x: colX[ci], y: 1.1, w: colWidths[ci], h: 0.4,
      fill: { color: C.navy }, line: { color: C.white, width: 0.3 } });
    s.addText(h, { x: colX[ci] + 0.03, y: 1.1, w: colWidths[ci] - 0.06, h: 0.4,
      fontSize: 9, bold: true, color: C.white, fontFace: "Calibri", valign: "middle", align: "center" });
  });

  rows.forEach((row, ri) => {
    const ry = 1.55 + ri * 0.68;
    const bg = ri % 2 === 0 ? C.white : C.mint;
    row.forEach((cell, ci) => {
      const bc = cell.includes("YES ⚠") ? C.lightred : bg;
      const tc = cell.includes("YES ⚠") ? C.red : (ci === 0 ? C.navy : C.text);
      s.addShape(pres.ShapeType.rect, { x: colX[ci], y: ry, w: colWidths[ci], h: 0.65,
        fill: { color: bc }, line: { color: C.navy, width: 0.2 } });
      s.addText(cell, { x: colX[ci] + 0.03, y: ry + 0.02, w: colWidths[ci] - 0.06, h: 0.61,
        fontSize: ci === 0 ? 9 : 8.5, bold: ci === 0, color: tc, fontFace: "Calibri", valign: "middle", wrap: true });
    });
  });

  s.addText("ADA 2026 · Section 9, Table 9.2  |  CI = contraindicated; HHF = hospitalization for heart failure", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 – CONTRAINDICATIONS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "CONTRAINDICATIONS", "Pharmacologic Contraindications & Precautions");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.red } });

  const cards = [
    { drug: "Metformin", ci: "eGFR <30 mL/min/1.73m²\nContrast media studies (hold 48h)\nActive hepatic impairment\nAlcohol abuse (↑ lactic acidosis risk)", color: C.navy },
    { drug: "SGLT2 Inhibitors", ci: "eGFR-based dosing (glucose effect ↓ at eGFR <45)\nT1DM (DKA risk)\nRecurrent UTI / predisposition to genital infections\nHold 3–4 days before surgery or prolonged fasting\nPregnancy", color: C.teal },
    { drug: "GLP-1 RA / Dual GIP-GLP1 RA", ci: "Personal or family history of medullary thyroid carcinoma\nMultiple Endocrine Neoplasia type 2 (MEN-2)\nHigh risk of pancreatitis (gallstones, severe hypertriglyceridemia)\nSevere GI motility disorders\nHold before procedures requiring anesthesia/deep sedation (aspiration risk)", color: C.sky },
    { drug: "DPP-4 Inhibitors", ci: "History of pancreatitis (use with caution)\nSaxagliptin / Alogliptin: caution in HF (↑ hospitalization risk)\nDose adjustment required for CKD (except linagliptin)", color: C.muted },
    { drug: "Sulfonylureas", ci: "CKD (↑ hypoglycemia; prefer glipizide over glibenclamide)\nElderly (hypoglycemia risk)\nPregnancy (insulin preferred)\nG6PD deficiency (some agents)", color: C.red },
    { drug: "Thiazolidinediones (TZD)", ci: "Heart failure (NYHA class III/IV) — absolute\nActive or history of bladder cancer (pioglitazone)\nOsteoporosis / fragility fracture risk (↑ fracture risk)\nLiver disease (use with caution)\nPregnancy", color: C.gold },
    { drug: "Insulin", ci: "No absolute contraindications\nCaution: Untreated hypoglycemia unawareness\nRequires dose adjustment with exercise, illness, fasting\nSulfonylurea/meglitinide dose should be ↓ when adding insulin", color: C.green },
  ];

  cards.forEach((card, i) => {
    const col = Math.floor(i / 4);
    const row = i % 4;
    const bx = 0.35 + col * 6.55;
    const by = 1.2 + row * 1.5;
    const bh = row === 2 ? 1.7 : 1.35;

    s.addShape(pres.ShapeType.rect, { x: bx, y: by, w: 6.3, h: bh,
      fill: { color: C.white }, line: { color: card.color, width: 1.2 } });
    s.addShape(pres.ShapeType.rect, { x: bx, y: by, w: 6.3, h: 0.4, fill: { color: card.color }, line: { color: card.color } });
    s.addText("⛔ " + card.drug, { x: bx + 0.08, y: by, w: 6.1, h: 0.4,
      fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    s.addText(card.ci, { x: bx + 0.1, y: by + 0.43, w: 6.1, h: bh - 0.5,
      fontSize: 9.5, color: C.text, fontFace: "Calibri", valign: "top", wrap: true });
  });

  s.addText("ADA 2026 · Section 9, Table 9.2  |  Always check current prescribing information", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 – NON-PHARM CONTRAINDICATIONS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "CONTRAINDICATIONS", "Non-Pharmacologic Contraindications & Precautions");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.red } });

  addInfoBox(s, "⚠ Exercise / Physical Activity Precautions",
    ["Uncontrolled hyperglycemia (>300 mg/dL or >250 with ketones) — defer vigorous activity",
     "Recent DKA or HHS — stabilize before resuming exercise",
     "Severe proliferative diabetic retinopathy — avoid high-intensity or jarring exercise (vitreous hemorrhage risk)",
     "Peripheral neuropathy / foot ulcers — non-weight-bearing exercise (swimming, cycling) preferred",
     "Autonomic neuropathy — orthostatic hypotension risk; cardiac screening before vigorous program",
     "On insulin/SU — carry fast-acting carbohydrate; check glucose pre/post exercise",
     "Recent MI or unstable angina — cardiology clearance before vigorous program"],
    0.4, 1.2, 6.1, 4.0, C.lightred, C.red
  );

  addInfoBox(s, "⚠ Dietary / Nutrition Precautions",
    ["Very low carbohydrate diets (<50g/day): requires insulin/SU dose adjustment to prevent hypoglycemia",
     "Fasting / time-restricted eating: coordinate with insulin dosing; not recommended without monitoring",
     "Protein restriction: avoid in CKD if further nephroprotection needed — consult renal dietitian",
     "Alcohol: moderate use only; risk of hypoglycemia (especially with SU/insulin) — do not drink on empty stomach",
     "Bariatric surgery post-op: risk of hypoglycemia, dumping syndrome, nutritional deficiencies"],
    0.4, 5.35, 6.1, 1.9, C.lightred, C.red
  );

  addInfoBox(s, "⚠ Metabolic Surgery Contraindications",
    ["Active substance use disorder",
     "Unstable psychiatric conditions (uncontrolled severe depression, psychosis, active suicidality)",
     "Inability to comply with long-term nutritional supplements and follow-up",
     "Active malignancy (relative CI)",
     "Pregnancy (relative CI)"],
    6.75, 1.2, 6.2, 2.5, C.lightred, C.red
  );

  addInfoBox(s, "⚠ DSMES / Behavioral Interventions — Cautions",
    ["Severe cognitive impairment — adapt education; caregiver-focused training essential",
     "Active mental health crisis — address psychiatric stability before intensive self-management training",
     "Health literacy limitations — use simple language, visual aids, teach-back; avoid complex carb counting if not feasible",
     "Social determinants of health (food insecurity, housing instability) — refer to social work; personalize goals"],
    6.75, 3.85, 6.2, 2.85, C.lightgold, C.gold
  );

  s.addText("ADA 2026 · Sections 5 & 8", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 – FOLLOW-UP & MONITORING SCHEDULE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "FOLLOW-UP", "Follow-Up Schedule & Complication Monitoring");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  // Schedule table
  s.addShape(pres.ShapeType.rect, { x: 0.4, y: 1.15, w: 7.8, h: 0.45, fill: { color: C.navy }, line: { color: C.navy } });
  s.addText("Monitoring Parameter", { x: 0.4, y: 1.15, w: 3.5, h: 0.45, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  s.addText("Frequency", { x: 3.95, y: 1.15, w: 2.1, h: 0.45, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
  s.addText("Notes", { x: 6.1, y: 1.15, w: 2.05, h: 0.45, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });

  const schedRows = [
    ["A1C", "Every 3 months (if not at goal)\nEvery 6 months (if stable at goal)", "NGSP-certified lab"],
    ["Blood Pressure", "Every visit", "Goal: <130/80 mmHg (most patients)"],
    ["Fasting Lipids", "Annually", "More often if on statin or abnormal"],
    ["eGFR + Serum Cr", "Annually", "More often if CKD present"],
    ["UACR", "Annually", "Spot urine ACR; if elevated, repeat x2"],
    ["Foot Exam", "At least annually\n(every visit if neuropathy)", "10-g monofilament + vibration sense"],
    ["Eye (Dilated) Exam", "Annually (or q2yr if stable)", "Ophthalmologist or optometrist"],
    ["Dental Exam", "Annually (at minimum)", "Bidirectional DM–periodontal disease link"],
    ["Vitamin B12", "Annually (if on metformin ≥4 yrs)", "Supplement if deficient"],
    ["Depression / Anxiety Screen", "Annually", "PHQ-9; refer if positive"],
    ["Diabetic Neuropathy Screen", "Annually", "Monofilament, vibration, ABI if vascular Sx"],
  ];

  schedRows.forEach((row, i) => {
    const ry = 1.65 + i * 0.5;
    const bg = i % 2 === 0 ? C.white : C.mint;
    [[0.4, 3.5], [3.95, 2.1], [6.1, 2.05]].forEach(([cx, cw], ci) => {
      s.addShape(pres.ShapeType.rect, { x: cx, y: ry, w: cw, h: 0.48, fill: { color: bg }, line: { color: C.navy, width: 0.2 } });
      s.addText(row[ci], { x: cx + 0.05, y: ry + 0.02, w: cw - 0.1, h: 0.44,
        fontSize: 9.5, bold: ci === 0, color: ci === 0 ? C.navy : C.text, fontFace: "Calibri", valign: "middle" });
    });
  });

  // Complication targets right side
  addInfoBox(s, "Complication Reduction Targets",
    ["BP: <130/80 mmHg (ADA 2026 general target)",
     "LDL-C: <70 mg/dL (established ASCVD); <100 mg/dL (no ASCVD)",
     "Non-HDL-C: <100 mg/dL (ASCVD); <130 mg/dL (no ASCVD)",
     "UACR: <30 mg/g (goal with SGLT2i/GLP-1 RA/ARB/ACEi)",
     "eGFR: preserve — SGLT2i + finerenone if CKD + albuminuria",
     "Weight: ≥5% loss for glycemic benefit; ≥10–15% for metabolic remission",
     "Smoking cessation: recommend at every visit"],
    8.45, 1.15, 4.6, 4.65, C.mint, C.navy
  );

  // Vaccines
  addInfoBox(s, "Immunizations (Section 4)",
    ["Influenza: annually", "COVID-19: per current recommendations",
     "Pneumococcal: PPSV23 (if <65) + PCV15 or PCV20; PCV + PPSV23 booster at ≥65",
     "Hepatitis B: unvaccinated adults <60 yrs", "Shingles (Zoster): age ≥50"],
    8.45, 5.95, 4.6, 1.22, C.lightgreen, C.green
  );

  s.addText("ADA 2026 · Sections 4, 6, 10–12", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 – SPECIAL POPULATIONS & COMORBIDITIES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSectionBanner(s, "SPECIAL POP.", "Special Populations & Comorbidity Management");
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 13.3, h: 6.5, fill: { color: C.offwhite } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  addInfoBox(s, "ASCVD / High CV Risk",
    ["GLP-1 RA with proven MACE benefit (semaglutide SQ/oral, liraglutide, dulaglutide)",
     "SGLT2i with proven HF benefit (empa, cana, dapa)",
     "Statin + ACEi/ARB first-line; consider ezetimibe/PCSK9i if LDL not at goal",
     "Aspirin 75–100 mg/day (established CVD); not routinely for primary prevention"],
    0.4, 1.2, 6.1, 2.1, C.mint, C.navy
  );

  addInfoBox(s, "CKD (Section 11)",
    ["SGLT2i (eGFR >20): slows CKD progression — continue until dialysis or transplant",
     "GLP-1 RA: reduces albuminuria (semaglutide SQ proven)",
     "Finerenone (non-steroidal MRA): added CKD + albuminuria benefit",
     "Avoid metformin if eGFR <30; adjust doses of most agents"],
    0.4, 3.45, 6.1, 2.1, C.mint, C.teal
  );

  addInfoBox(s, "Elderly / Frail Adults",
    ["Less stringent A1C goal acceptable (7.5–8.0% or even 8.5% if frail/limited life expectancy)",
     "Avoid hypoglycemia — prefer DPP-4i, low-dose GLP-1 RA",
     "Avoid SU (especially glibenclamide) — high hypoglycemia risk",
     "Simplify regimens; consider dose reductions; deintensification appropriate"],
    0.4, 5.7, 6.1, 1.55, C.lightgold, C.gold
  );

  addInfoBox(s, "Obesity / Overweight (Section 8)",
    ["First-line for weight-loss: GLP-1 RA or dual GIP/GLP-1 RA (tirzepatide)",
     "Tirzepatide: up to ~22% body weight loss in T2DM trials",
     "Metabolic surgery (BMI ≥40 or ≥35 with comorbidities) — can achieve remission",
     "Avoid TZDs, insulin titration without weight-loss adjuncts"],
    6.75, 1.2, 6.2, 2.1, C.mint, C.teal
  );

  addInfoBox(s, "Heart Failure (Section 10)",
    ["SGLT2i first-line: dapagliflozin, empagliflozin — reduce HF hospitalization & CV death",
     "Saxagliptin and alogliptin: associated with ↑ HF hospitalization — avoid in HF",
     "TZDs: cause fluid retention → worsen HF — avoid in NYHA class III/IV",
     "GLP-1 RA: neutral on HF outcomes (except semaglutide in HFpEF trial — modest benefit)"],
    6.75, 3.45, 6.2, 2.1, C.mint, C.navy
  );

  addInfoBox(s, "Pregnancy / Preconception",
    ["Insulin is the preferred glucose-lowering agent (safest data)",
     "Metformin and glyburide: used in GDM but cross placenta — less preferred by ADA",
     "GLP-1 RA, SGLT2i, DPP-4i: not recommended in pregnancy (limited safety data)",
     "Target A1C: 6.0–6.5% preconception; <6.0% if achievable without hypoglycemia"],
    6.75, 5.7, 6.2, 1.55, C.lightred, C.red
  );

  s.addText("ADA 2026 · Sections 10, 11, 13, 15", { x: 0, y: 7.12, w: 13.3, h: 0.3, fontSize: 9, color: C.white, align: "center", fontFace: "Calibri" });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 – SUMMARY / KEY TAKEAWAYS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addDarkSlide(s, "KEY TAKEAWAYS", "ADA Standards of Care in Diabetes 2026");

  const takeaways = [
    "Diagnose T2DM: A1C ≥6.5%, FPG ≥126 mg/dL, 2-h PG ≥200 mg/dL, or random PG ≥200 + Sx — confirm with 2 tests",
    "Start pharmacotherapy at diagnosis (no delay) — metformin + lifestyle modification as foundation",
    "GLP-1 RA preferred over insulin for most T2DM patients not at goal (Rec 9.21); tirzepatide offers greatest weight loss",
    "SGLT2 inhibitors and GLP-1 RA have proven cardiorenal benefits — use in ASCVD, HF, and CKD",
    "Glycemic goal: A1C <7.0% for most adults — individualize based on age, comorbidities, hypoglycemia risk, patient preference",
    "Monitor annually: A1C, lipids, eGFR, UACR, foot exam, dilated eye exam, and BP",
    "Avoid SGLT2i before surgery (3–4 days), TZDs in HF, SU in CKD/elderly, GLP-1 RA in MTC/MEN-2",
    "Address social determinants of health, weight management, and DSMES at every care interaction",
  ];

  takeaways.forEach((t, i) => {
    const ty = 1.65 + i * 0.62;
    s.addShape(pres.ShapeType.rect, { x: 0.5, y: ty, w: 12.3, h: 0.55,
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 – REFERENCES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 1.0, w: 0.18, h: 6.5, fill: { color: C.teal } });

  const refs = [
    "ADA Professional Practice Committee. Introduction and methodology: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S1–S5.",
    "ADA Professional Practice Committee. Diagnosis and classification of diabetes: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S27–S49.",
    "ADA Professional Practice Committee. Prevention or delay of diabetes: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S50–S60.",
    "ADA Professional Practice Committee. Comprehensive medical evaluation and assessment of comorbidities: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S61–S88.",
    "ADA Professional Practice Committee. Glycemic goals, hypoglycemia, and hyperglycemic crises: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S132–S149.",
    "ADA Professional Practice Committee. Obesity and weight management for the prevention and treatment of diabetes: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1).",
    "ADA Professional Practice Committee. Pharmacologic approaches to glycemic treatment: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S183–S215.",
    "ADA Professional Practice Committee. Cardiovascular disease and risk management: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S216–S245.",
    "ADA Professional Practice Committee. Chronic kidney disease and risk management: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1):S246–S260.",
    "ADA Professional Practice Committee. Older adults: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1).",
    "ADA Professional Practice Committee. Management of diabetes in pregnancy: Standards of Care in Diabetes—2026. Diabetes Care 2026;49(Suppl. 1).",
  ];

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// ── WRITE FILE ─────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/t2dm-presentation/T2DM_ADA2026_Presentation.pptx" })
  .then(() => console.log("✅ Done: T2DM_ADA2026_Presentation.pptx"))
  .catch(e => console.error("❌ Error:", e));

const pptxgen = require("pptxgenjs");
const prs = new pptxgen();
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prs.title = "Type 2 Diabetes Mellitus – ADA Standards of Care 2026";

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// HELPERS
// ─────────────────────────────────────────────────────────────────────────────

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function titleSlide(s, title, sub) {
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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 1  —  TITLE
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  titleSlide(s,"TYPE 2 DIABETES MELLITUS","Comprehensive Clinical Presentation  ·  ADA Standards of Care 2026");
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 2  —  OVERVIEW
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
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  card(s,"Definition (ADA 2026)",
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// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 3  —  CLASSIFICATION
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"CLASSIFICATION","ADA 2026 Classification of Diabetes Mellitus");

  const types=[
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    {label:"Gestational DM",desc:"Diagnosed in 2nd/3rd trimester.\nNot clearly overt DM prior to gestation.\nScreen all at 24–28 wks.",color:C.gold},
    {label:"Other Specific Types",desc:"Monogenic DM (MODY, neonatal DM)\nPancreatic disease (Type 3c)\nDrug-induced (glucocorticoids, antipsychotics)\nPost-transplant DM (PTDM)",color:C.muted},
  ];
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  s.addText("★ AABBCC Tool (when T1 vs T2 unclear): Age <35→T1 | Autoimmunity | Body habitus BMI<25→T1 | Background family Hx | Control (can't reach goal on non-insulin) | Comorbidities (e.g., ICI therapy)",
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}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 4  —  DIAGNOSTIC CRITERIA
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
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  table(s,
    [["Test","Threshold","Notes"],
     ["A1C","≥ 6.5%  (≥48 mmol/mol)","NGSP-certified, DCCT-standardized lab required"],
     ["Fasting Plasma Glucose (FPG)","≥ 126 mg/dL  (≥7.0 mmol/L)","Fasting = no caloric intake ≥8 hours"],
     ["2-h PG during 75g OGTT","≥ 200 mg/dL  (≥11.1 mmol/L)","150g carbs/day x3 days before test (WHO protocol)"],
     ["Random Plasma Glucose + Sx","≥ 200 mg/dL  (≥11.1 mmol/L)","Classic Sx: polyuria, polydipsia, unexplained weight loss"],
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  // Prediabetes table
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     ["A1C","5.7–6.4%  (39–47 mmol/mol)","—"],
     ["FPG","100–125 mg/dL  (5.6–6.9 mmol/L)","Impaired Fasting Glucose (IFG)"],
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  // A1C limitations
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    ["Hemoglobin variants (sickle cell trait)","Altered RBC turnover: anemia, hemolysis, G6PD deficiency","HIV, cirrhosis, CKD, dialysis","Pregnancy (iron deficiency → falsely ↑ A1C)","Recent blood transfusion or erythropoietin use"],
    8.65,1.1,4.3,5.0,C.red,C.redLight);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 5  —  SCREENING FLOWCHART
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"SCREENING","Who, When & How to Screen for T2DM");

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     "First-degree relative with diabetes",
     "High-risk race/ethnicity (African American, Latino, Native American, Asian American)",
     "History of cardiovascular disease",
     "HTN ≥130/80 mmHg or on antihypertensive therapy",
     "HDL <35 mg/dL and/or TG >250 mg/dL",
     "Polycystic ovary syndrome (PCOS)",
     "Physical inactivity or acanthosis nigricans",
     "MASLD, severe obesity"],
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  card(s,"Special Groups — Screen Regardless of BMI",
    ["ALL adults: begin screening at age 35",
     "Prior GDM → every 1–3 years",
     "Prediabetes → annually",
     "On glucocorticoids, statins, thiazides → at start",
     "On antipsychotics → baseline + 12–16 wks + annually",
     "HIV → FPG before ARV, at switch, 3–6 months after"],
    0.3,5.25,5.2,2.0,C.teal,C.white);

  // RIGHT: flowchart boxes
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    {col:C.teal,   text:"STEP 1\nRisk Assessment\n(Age ≥35? Overweight + RF? Prediabetes?)"},
    {col:C.sky,    text:"STEP 2\nChoose Test\nFPG or A1C (outpatient preferred)\nOR 2-h 75g OGTT (most sensitive)"},
    {col:C.gold,   text:"STEP 3\nInterpret Result\nNormal / Prediabetes / Diabetes"},
    {col:C.navy,   text:"STEP 4\nClassify Type & Begin Treatment\n(AABBCC tool if T1 vs T2 unclear)"},
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    if(i<steps.length-1) darrow(s,9.85,2.17+i*1.24);
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  // Interval note
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  s.addText("Normal result → repeat every 3 years minimum  |  Sooner if weight gain or new risk factors arise",
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}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 6  —  LABS & BASELINE WORKUP
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"LABS","Laboratory Evaluation at Diagnosis & Ongoing Monitoring");

  card(s,"Initial Workup at T2DM Diagnosis",
    ["A1C (NGSP-certified lab) — confirms diagnosis & baseline","Fasting lipid panel: LDL-C, HDL-C, TG, Total Cholesterol",
     "Serum creatinine + eGFR — baseline kidney function","Urine albumin-to-creatinine ratio (UACR) — nephropathy screen",
     "LFTs (ALT/AST) — MASLD screen; pre-metformin baseline","TSH — thyroid disease associated with DM",
     "Vitamin B12 — baseline if starting metformin","Blood pressure — every visit; goal <130/80 mmHg",
     "BMI + weight — every visit","Foot exam (10g monofilament + vibration) — baseline neuropathy",
     "Dilated fundus exam — baseline retinopathy"],
    0.3,1.1,6.1,5.9,C.navy,C.white);

  // Glycemic monitoring table
  s.addText("Glycemic Monitoring Options (Section 6)",{x:6.65,y:1.1,w:6.3,h:0.38,fontSize:13,bold:true,color:C.navy,fontFace:"Calibri"});
  table(s,
    [["Method","What It Measures","When to Use"],
     ["A1C","2–3 month avg glucose","Standard; ≥2x/yr (stable) or q3mo (not at goal)"],
     ["CGM — TIR","% time 70–180 mg/dL","On insulin; frequent hypoglycemia"],
     ["CGM — TBR","% time <70 mg/dL","Key safety metric; all insulin users"],
     ["CGM — TAR","%  time >180 mg/dL","Assess postprandial control"],
     ["GMI","Estimated A1C from CGM","When A1C and CGM discordant"],
     ["BGM (fingerstick)","Point-in-time glucose","Adjunct; cost-effective"],
     ["Fructosamine / Gly-albumin","~2–3 wk avg","When A1C unreliable (hemoglobinopathy, CKD, pregnancy)"],
    ],
    null,[2.1,2.2,2.4],6.65,1.52,0.5,C.navy,C.slate);

  card(s,"Monitoring Frequency (Recs 6.2–6.4)",
    ["Stable at goal: A1C every 6 months","Not at goal or medication change: every 3 months",
     "CGM preferred over BGM when available","BP + weight: every visit"],
    6.65,5.62,6.3,1.45,C.teal,C.white);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 7  —  GLYCEMIC TARGETS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"TARGETS","Glycemic Goals — ADA 2026 (Section 6)");

  // A1C targets
  s.addText("A1C Targets by Population",{x:0.3,y:1.1,w:6.1,h:0.38,fontSize:13,bold:true,color:C.navy,fontFace:"Calibri"});
  table(s,
    [["Population","A1C Target"],
     ["Most non-pregnant adults","< 7.0%  (<53 mmol/mol)"],
     ["Young/newly diagnosed, long life expectancy, no hypoglycemia risk","< 6.5% if safely achievable"],
     ["Frail elderly, limited life expectancy, high hypoglycemia risk","< 8.0–8.5%"],
     ["Pregnancy — preconception","< 6.0–6.5%"],
     ["Pregnancy — during gestation","< 6.0% (if without significant hypoglycemia)"],
    ],
    null,[3.4,2.65],0.3,1.52,0.58,C.navy,C.slate);

  // CGM targets
  s.addText("CGM-Based Glycemic Targets",{x:0.3,y:4.82,w:6.1,h:0.38,fontSize:13,bold:true,color:C.teal,fontFace:"Calibri"});
  table(s,
    [["CGM Metric","Standard Target","Elderly / High-Risk"],
     ["TIR  (70–180 mg/dL)","> 70%","> 50%"],
     ["TBR  (< 70 mg/dL)","< 4%","< 4%"],
     ["Critical low  (< 54 mg/dL)","< 1%","< 1%"],
     ["TAR  (> 180 mg/dL)","< 25%","—"],
    ],
    null,[2.9,1.7,1.65],0.3,5.24,0.5,C.teal,C.slate);

  // BGM targets + principles
  card(s,"BGM Fingerstick Targets",
    "Pre-meal: 80–130 mg/dL\nPeak postprandial (1–2 hrs after meal start): < 180 mg/dL",
    6.65,1.1,6.3,1.25,C.sky,C.white);

  card(s,"Key Individualization Principles",
    ["Tighter control: young patients, newly diagnosed, no comorbidities","Relaxed goals: frail elderly, dementia, recurrent severe hypoglycemia, limited life expectancy, high treatment burden","Shared decision-making — involve patient in goal-setting","Reassess and adjust goals at every clinical encounter","De-intensify therapy when goals are too stringent and burdensome"],
    6.65,2.5,6.3,3.25,C.navy,C.white);

  card(s,"A1C vs CGM — Use Both",
    "A1C and CGM metrics are complementary. CGM captures hypoglycemia and glycemic variability that A1C misses. Use both when available. (Rec 6.1)",
    6.65,5.92,6.3,1.15,C.teal,C.white);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 8  —  NON-PHARMACOLOGIC TREATMENT
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"NON-PHARM Tx","Non-Pharmacologic Treatment & Lifestyle Management");

  card(s,"Medical Nutrition Therapy (MNT)",
    ["Goal: 5–10% weight reduction → meaningful glycemic improvement","≥15% loss may achieve T2DM remission (DiRECT/DIADEM-I trials)",
     "No single optimal diet — Mediterranean, DASH, low-carb, plant-based all supported",
     "Reduce: refined carbs, added sugars, ultra-processed foods, sodium (<2,300 mg/day)",
     "Increase: dietary fiber (vegetables, legumes, whole grains)","Limit alcohol — hypoglycemia risk with SU/insulin",
     "Referral to registered dietitian for individualized MNT counseling"],
    0.3,1.1,6.1,3.25,C.navy,C.white);

  card(s,"Physical Activity (Section 5)",
    ["Aerobic: ≥150 min/week moderate-intensity (brisk walk, cycling, swimming)",
     "Resistance training: ≥2 days/week — improves insulin sensitivity independently",
     "Break prolonged sitting every 30 minutes","Benefits: A1C ↓ ~0.5–1.0%, weight ↓, BP ↓, lipid improvement",
     "⚠ Pre-exercise glucose check if on insulin or sulfonylurea","Carry fast-acting carbohydrate (SU/insulin users)"],
    0.3,4.5,6.1,2.6,C.teal,C.white);

  card(s,"DSMES — Diabetes Self-Management Education & Support",
    ["Recommended at: diagnosis, annually, when complicating factors arise, care transitions",
     "ADA-recognized or CDC-recognized DPP programs","Covers: self-monitoring, medication management, foot care, sick-day rules, hypoglycemia rescue",
     "Teach-back method — assess health literacy","Address social determinants of health (SDOH): food security, housing, transportation"],
    6.65,1.1,6.3,2.7,C.sky,C.white);

  card(s,"Weight Management (Section 8)",
    ["5–10% weight loss → clinically meaningful glycemic benefit","≥15% weight loss associated with T2DM remission",
     "Intensive lifestyle intervention (ILI) + VLCD (very low calorie diet) supported",
     "Metabolic/bariatric surgery: BMI ≥40 (or ≥35 with comorbidities)",
     "GLP-1 RA and dual GIP/GLP-1 RA: first-line pharmacologic weight management adjuncts"],
    6.65,3.95,6.3,2.3,C.gold,C.goldLight);

  card(s,"Tobacco & Behavioral",
    "Smoking cessation at every visit. Alcohol: moderate use only — no drinking on empty stomach (hypoglycemia risk with SU/insulin). Screen depression (PHQ-9) annually.",
    6.65,6.4,6.3,0.85,C.muted,C.white);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 9  —  PHARMACOLOGIC ALGORITHM
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"PHARM Tx","Pharmacologic Treatment Algorithm — ADA 2026");

  s.addShape(prs.ShapeType.rect,{x:0.3,y:1.05,w:12.7,h:0.5,fill:{color:C.goldLight},line:{color:C.gold,width:0.5}});
  s.addText("⚡ Key principle: Start pharmacotherapy AT DIAGNOSIS — do not delay. GLP-1–based therapy preferred over insulin (unless A1C >10% or glucose ≥300 mg/dL). (Recs 9.15, 9.21)",
    {x:0.4,y:1.06,w:12.5,h:0.48,fontSize:10.5,color:C.text,italic:true,fontFace:"Calibri",valign:"middle"});

  // Step 1
  s.addShape(prs.ShapeType.rect,{x:0.3,y:1.65,w:12.7,h:1.55,fill:{color:C.navy},line:{color:C.navyDark,width:0.5}});
  s.addText("STEP 1 — All T2DM at Diagnosis",{x:0.4,y:1.68,w:3.5,h:0.42,fontSize:13,bold:true,color:C.gold,fontFace:"Calibri"});
  s.addText("✅ Metformin (unless contraindicated)   ✅ Lifestyle modification (MNT + physical activity)   ✅ DSMES referral   ✅ Address SDOH",
    {x:0.4,y:2.12,w:12.5,h:0.9,fontSize:11.5,color:C.white,fontFace:"Calibri",valign:"middle"});

  // Step 2
  s.addShape(prs.ShapeType.rect,{x:0.3,y:3.32,w:12.7,h:0.4,fill:{color:C.teal},line:{color:C.teal}});
  s.addText("STEP 2 — Comorbidity-Driven Add-On Therapy  (when A1C not at goal)",
    {x:0.4,y:3.33,w:12.5,h:0.38,fontSize:13,bold:true,color:C.white,fontFace:"Calibri",valign:"middle"});

  const step2=[
    {label:"ASCVD / High CV Risk",drug:"GLP-1 RA (sema, lira, dula)\nOR SGLT2i (empa, cana, dapa)",col:C.sky},
    {label:"Heart Failure (HFrEF/HFpEF)",drug:"SGLT2 Inhibitor\n(empa, cana, dapa)",col:C.teal},
    {label:"Chronic Kidney Disease",drug:"SGLT2i + GLP-1 RA\n+ Finerenone (if albuminuria)",col:C.navy},
    {label:"Need Weight Loss",drug:"GLP-1 RA or Dual GIP/GLP-1 RA\n(tirzepatide — highest weight loss)",col:C.gold},
    {label:"Minimize Hypoglycemia",drug:"DPP-4i, GLP-1 RA, SGLT2i\n(all low hypoglycemia risk)",col:C.green},
    {label:"Cost Concern",drug:"Sulfonylurea, TZD\nNPH insulin (generic)",col:C.muted},
  ];
  step2.forEach((st,i)=>{
    const bx=0.3+(i%3)*4.25; const by=3.8+(i>2?1.55:0);
    s.addShape(prs.ShapeType.rect,{x:bx,y:by,w:4.1,h:1.45,fill:{color:C.white},line:{color:st.col,width:1.2}});
    s.addShape(prs.ShapeType.rect,{x:bx,y:by,w:4.1,h:0.38,fill:{color:st.col},line:{color:st.col}});
    s.addText(st.label,{x:bx+0.08,y:by,w:3.94,h:0.38,fontSize:10.5,bold:true,color:C.white,fontFace:"Calibri",valign:"middle"});
    s.addText(st.drug,{x:bx+0.1,y:by+0.42,w:3.9,h:0.95,fontSize:10,color:C.text,fontFace:"Calibri",valign:"middle",wrap:true});
  });

  // Step 3
  s.addShape(prs.ShapeType.rect,{x:0.3,y:6.97,w:12.7,h:0.37,fill:{color:C.red},line:{color:C.red}});
  s.addText("STEP 3 — Severe Hyperglycemia: A1C >10% or BG ≥300 mg/dL or Symptomatic → Initiate Insulin (basal first). Combine with GLP-1 RA (Rec 9.22). ↓ SU when adding insulin (Rec 9.17).",
    {x:0.4,y:6.97,w:12.5,h:0.36,fontSize:9.5,color:C.white,fontFace:"Calibri",valign:"middle"});
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 10  —  DRUG CLASSES PART 1
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"MEDICATIONS 1","Drug Classes — Metformin, SGLT2i & GLP-1 RA");

  card(s,"Metformin — First-Line Agent",
    ["MOA: ↓ hepatic glucose output (AMPK activation) + ↑ insulin sensitivity","Efficacy: High — A1C ↓ ~1.0–1.5%  |  Hypoglycemia risk: None",
     "Weight: Neutral (modest loss possible)","AEs: GI (nausea, diarrhea) — mitigate with slow titration, ER formulation, give with food",
     "Monitor Vitamin B12 if on ≥4 years (deplete B12)","CI: eGFR <30; active liver disease; alcohol abuse; hold with IV contrast (48h)"],
    0.3,1.1,6.1,2.75,C.navy,C.white);

  card(s,"SGLT2 Inhibitors (empagliflozin, canagliflozin, dapagliflozin, ertugliflozin)",
    ["MOA: Block SGLT2 in proximal tubule → glucosuria (excrete ~150g glucose/day)",
     "Efficacy: Intermediate–High (A1C ↓ 0.5–1.0%)  |  Hypoglycemia risk: None",
     "CV benefits: ↓ MACE (empa, cana), ↓ HF hospitalization (empa, cana, dapa, ertu), ↓ CKD progression",
     "Weight: Moderate loss (~2–3 kg)","AEs: Genital mycotic infections, UTI, DKA (rare in T2DM), Fournier's gangrene (rare), volume depletion",
     "CI: T1DM (↑ DKA risk); hold 3–4 days pre-surgery; eGFR <20"],
    0.3,3.98,6.1,3.1,C.teal,C.white);

  card(s,"GLP-1 Receptor Agonists (semaglutide, liraglutide, dulaglutide, exenatide)",
    ["MOA: GLP-1 mimetic → glucose-dependent insulin ↑, glucagon ↓, ↓ gastric emptying, ↑ satiety",
     "Efficacy: High–Very High (A1C ↓ 1.0–1.8%)  |  Semaglutide = highest efficacy",
     "CV: ↓ MACE (sema SQ/oral, lira, dula); ↓ albuminuria; sema SQ → ↓ CKD progression","Weight: 5–10% body weight loss",
     "AEs: Nausea/vomiting (dose-dependent), pancreatitis (rare), biliary disease, NAION (rare)",
     "CI: Personal/family Hx MTC or MEN-2; hold before general anesthesia (aspiration risk)"],
    6.65,1.1,6.3,3.0,C.sky,C.white);

  card(s,"Dual GIP/GLP-1 RA — Tirzepatide (Mounjaro®)",
    ["MOA: Dual agonist — activates GIP + GLP-1 receptors simultaneously",
     "Efficacy: Very High — A1C ↓ ~2.0–2.4% (SURPASS trials) — highest of any non-insulin agent",
     "Weight: Very High loss — up to ~22% body weight (SURMOUNT trials)",
     "CV: Tirzepatide HFpEF trial (SUMMIT) — reduced HF outcomes; MACE outcome trial ongoing",
     "AEs: Same GI profile as GLP-1 RA; same thyroid C-cell / pancreatitis precautions"],
    6.65,4.23,6.3,2.85,C.gold,C.goldLight);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 11  —  DRUG CLASSES PART 2
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"MEDICATIONS 2","Drug Classes — DPP-4i, Sulfonylureas, TZDs & Insulin");

  card(s,"DPP-4 Inhibitors (sitagliptin, saxagliptin, alogliptin, linagliptin)",
    ["MOA: Inhibit DPP-4 → prevent GLP-1/GIP breakdown → ↑ incretin effect",
     "Efficacy: Moderate (A1C ↓ ~0.5–0.8%)  |  Hypoglycemia risk: None  |  Weight: Neutral",
     "AEs: Pancreatitis (rare); saxagliptin/alogliptin → ↑ HF hospitalization risk",
     "Dose-adjust for CKD (except linagliptin — hepatically cleared)"],
    0.3,1.1,6.1,2.3,C.sky,C.white);

  card(s,"Sulfonylureas (glipizide, glimepiride, glyburide/glibenclamide)",
    ["MOA: Stimulate β-cell insulin release via ATP-sensitive K⁺ channel closure (glucose-independent)",
     "Efficacy: High (A1C ↓ ~1.0–1.5%)  |  ⚠ Hypoglycemia risk: HIGH  |  Weight: Gain (~2 kg)",
     "Preferred agent: glipizide (shortest acting) — safer in elderly/CKD","Avoid glibenclamide in elderly or CKD — prolonged severe hypoglycemia",
     "CI: Pregnancy (use insulin); severe renal/hepatic impairment"],
    0.3,3.52,6.1,2.5,C.red,C.redLight);

  card(s,"Thiazolidinediones / TZDs (pioglitazone)",
    ["MOA: PPARγ agonist → ↑ adipose insulin sensitivity; ↑ hepatic and muscle glucose uptake",
     "Efficacy: High (A1C ↓ ~0.8–1.4%); durable effect  |  Hypoglycemia risk: None",
     "CV: Pioglitazone — CV benefit (PROactive trial)  |  MASLD: hepatic benefit",
     "AEs: Fluid retention/edema, weight gain, ↑ fracture risk, bladder cancer risk (pioglitazone)",
     "CI: HF NYHA class III/IV (absolute); bladder cancer Hx; osteoporosis; pregnancy"],
    0.3,6.15,6.1,1.05,C.muted,C.white);

  card(s,"Insulin Therapy",
    ["No absolute contraindications — highest efficacy; no ceiling effect","⚠ Hypoglycemia risk: HIGH  |  Weight: Gain",
     "Types: Rapid (lispro, aspart, glulisine), Ultra-rapid (URAA), Short (regular), Intermediate (NPH), Long-acting (glargine U-100/U-300, detemir, degludec)",
     "Basal insulin: preferred initial insulin for T2DM (start once daily)",
     "GLP-1 RA + insulin combination preferred over insulin alone (Rec 9.22)",
     "↓ SU/meglitinide dose when adding insulin — ↑ hypoglycemia risk otherwise (Rec 9.17)",
     "Adjust dose with exercise, illness, and fasting; sick-day rules education essential"],
    6.65,1.1,6.3,3.5,C.navy,C.white);

  card(s,"Combination Avoid",
    ["DPP-4i + GLP-1 RA: no additive glucose-lowering benefit; do NOT combine (Rec 9.18)","TZD + Insulin: ↑ fluid retention → ↑ HF risk","Glibenclamide in elderly or CKD: prolonged severe hypoglycemia"],
    6.65,4.75,6.3,2.35,C.red,C.redLight);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 12  —  DRUG COMPARISON TABLE
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"DRUG TABLE","Glucose-Lowering Agents — Key Comparison (ADA 2026, Table 9.2)");

  table(s,
    [["Agent","Efficacy","Hypo?","Weight","CV Effect","Kidney Effect","Key AE / CI"],
     ["Metformin","High","No","Neutral/↓ slightly","Potential benefit","Neutral","GI; B12↓; CI: eGFR <30"],
     ["SGLT2i","Intermediate–High","No","Loss","↓ MACE/HF (proven)","↓ CKD progression","Genital infxn; DKA (rare); hold pre-surg"],
     ["GLP-1 RA","High–Very High","No","Loss (mod–high)","↓ MACE (sema, lira, dula)","↓ Albuminuria","Nausea; pancreatitis; CI: MTC/MEN-2"],
     ["Dual GIP/GLP-1 RA (tirzepatide)","Very High","No","Very High Loss","↓ HF (SUMMIT)","Potential benefit","GI; same as GLP-1 RA precautions"],
     ["DPP-4 Inhibitors","Moderate","No","Neutral","Neutral","Neutral","Pancreatitis (rare); sax/alo → ↑ HHF"],
     ["Sulfonylureas","High","⚠ YES","Gain","Neutral","Neutral","Hypoglycemia; wt gain; ⚠ CKD/elderly"],
     ["TZDs (pioglitazone)","High","No","Gain","Benefit (pio)","Neutral","Edema; fractures; bladder CA; CI: HF III/IV"],
     ["Insulin","Highest","⚠ YES","Gain","Neutral","Neutral","Hypoglycemia; wt gain; injection site"],
    ],
    null,[2.05,1.15,0.75,1.3,1.8,1.6,4.45],0.28,1.1,0.54,C.navy,C.slate);

  s.addShape(prs.ShapeType.rect,{x:0.28,y:6.43,w:12.74,h:0.4,fill:{color:C.goldLight},line:{color:C.gold,width:0.4}});
  s.addText("⚠ Red = hypoglycemia risk  |  CI = contraindicated  |  HHF = hospitalization for heart failure  |  MTC = medullary thyroid carcinoma  |  Always verify current prescribing information",
    {x:0.38,y:6.44,w:12.54,h:0.38,fontSize:9,color:C.text,fontFace:"Calibri",valign:"middle"});
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 13  —  PHARMACOLOGIC CONTRAINDICATIONS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"CONTRAINDICATIONS","Pharmacologic Contraindications & Precautions");

  const ciCards=[
    {drug:"Metformin",ci:"• eGFR <30 mL/min/1.73m² — absolute CI\n• eGFR 30–45: use with caution, monitor kidney function\n• Active liver disease / alcohol abuse (↑ lactic acidosis)\n• Hold 48h before iodinated contrast studies\n• Hold perioperatively for major procedures",col:C.navy},
    {drug:"SGLT2 Inhibitors",ci:"• T1DM — ↑ DKA risk (absolute CI)\n• Hold 3–4 days before surgery, prolonged fasting, or critical illness\n• Glucose-lowering effect ↓ at eGFR <45 (but continue for CV/renal benefit if eGFR >20)\n• Recurrent UTI or predisposition to genital infections\n• Pregnancy",col:C.teal},
    {drug:"GLP-1 RA / Tirzepatide",ci:"• Personal OR family history of medullary thyroid carcinoma (MTC) — absolute CI\n• Multiple Endocrine Neoplasia type 2 (MEN-2) — absolute CI\n• High risk pancreatitis (gallstones, severe hypertriglyceridemia)\n• Severe GI motility disorders (gastroparesis)\n• Hold before procedures requiring general anesthesia/deep sedation (aspiration risk)\n• Pregnancy",col:C.sky},
    {drug:"DPP-4 Inhibitors",ci:"• History of pancreatitis — relative CI; use with caution\n• Saxagliptin & alogliptin: ↑ HF hospitalization risk — avoid in HF\n• Dose adjustment required for CKD (ALL agents except linagliptin)\n• Avoid saxagliptin if eGFR <15",col:C.muted},
    {drug:"Sulfonylureas",ci:"• Pregnancy — use insulin instead (sulfonylureas cross placenta)\n• Severe CKD — especially avoid glibenclamide (prolonged hypoglycemia)\n• Frail elderly — ↑ fall & hypoglycemia risk; prefer shorter-acting (glipizide)\n• G6PD deficiency (some agents — rare hemolysis)\n• Significant hepatic impairment",col:C.red},
    {drug:"TZDs (Pioglitazone)",ci:"• HF NYHA Class III or IV — absolute CI (fluid retention worsens HF)\n• Active bladder cancer or Hx of bladder cancer (pioglitazone)\n• Osteoporosis / high fracture risk — TZDs ↑ fracture risk especially in women\n• Active/significant liver disease\n• Pregnancy",col:C.gold},
  ];

  ciCards.forEach((c,i)=>{
    const col=i%3; const row=Math.floor(i/3);
    const bx=0.28+col*4.33; const by=1.1+row*3.08;
    s.addShape(prs.ShapeType.rect,{x:bx,y:by,w:4.18,h:2.92,fill:{color:C.white},line:{color:c.col,width:1.2},
      shadow:{type:"outer",blur:4,offset:2,angle:45,color:"999999",opacity:0.15}});
    s.addShape(prs.ShapeType.rect,{x:bx,y:by,w:4.18,h:0.44,fill:{color:c.col},line:{color:c.col}});
    s.addText("⛔  "+c.drug,{x:bx+0.08,y:by,w:4.0,h:0.44,fontSize:12,bold:true,color:C.white,fontFace:"Calibri",valign:"middle"});
    s.addText(c.ci,{x:bx+0.1,y:by+0.48,w:3.98,h:2.37,fontSize:9.5,color:C.text,fontFace:"Calibri",valign:"top",wrap:true});
  });

  s.addShape(prs.ShapeType.rect,{x:0.28,y:7.15,w:12.74,h:0.2,fill:{color:C.redLight},line:{color:C.red,width:0.3}});
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 14  —  NON-PHARMACOLOGIC CONTRAINDICATIONS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"NON-PHARM CI","Non-Pharmacologic Contraindications & Precautions");

  card(s,"⚠ Exercise & Physical Activity — Defer or Modify When:",
    ["BG >300 mg/dL (or >250 with ketones) — stabilize before vigorous activity",
     "Recent DKA or HHS — full recovery and medical clearance required first",
     "Severe proliferative diabetic retinopathy — avoid high-intensity or jarring exercise (vitreous hemorrhage risk)",
     "Peripheral neuropathy / active foot ulcer — non-weight-bearing exercise preferred (swimming, cycling)",
     "Autonomic neuropathy — orthostatic hypotension risk; cardiac screening before starting vigorous program",
     "On insulin or sulfonylurea — carry fast-acting carbohydrate; check BG pre/during/post exercise",
     "Recent MI, unstable angina, or decompensated HF — cardiology clearance required"],
    0.3,1.1,6.1,4.05,C.red,C.redLight);

  card(s,"⚠ Dietary & Nutritional Precautions",
    ["Very low carbohydrate diet (<50g/day) — ↓ insulin/SU dose to prevent hypoglycemia; monitor closely",
     "Extended fasting / time-restricted eating — coordinate with insulin dosing; not recommended without monitoring plan",
     "High-protein diet in CKD — may worsen kidney function; consult renal dietitian",
     "Alcohol — hypoglycemia with SU/insulin; never on empty stomach; limit to moderate use",
     "Post-bariatric surgery — risk of dumping syndrome, hypoglycemia, B12/iron/Ca²⁺/vitamin D deficiency"],
    0.3,5.3,6.1,1.9,C.red,C.redLight);

  card(s,"⚠ Metabolic/Bariatric Surgery Contraindications",
    ["Active substance use disorder","Unstable psychiatric conditions (uncontrolled severe depression, psychosis, active suicidality)",
     "Inability to comply with post-op nutritional supplements and lifelong follow-up",
     "Active malignancy (relative CI)","Pregnancy (relative CI)","Severe cardiac/pulmonary disease (anesthesia risk — relative)"],
    6.65,1.1,6.3,2.55,C.red,C.redLight);

  card(s,"⚠ DSMES & Behavioral — Adaptations Required",
    ["Severe cognitive impairment — caregiver-focused education; simplified regimens; avoid complex carb counting",
     "Active mental health crisis — stabilize psychiatric condition before intensive self-management training",
     "Health literacy limitations — use visual aids, simple language, teach-back method; written action plans",
     "Food insecurity — refer to social work; meal planning that accounts for real food access; community resources"],
    6.65,3.8,6.3,2.35,C.gold,C.goldLight);

  card(s,"DSMES — When Caution with Intensive Goals",
    "Frail elderly / dementia: simplify regimen; avoid targets that increase hypoglycemia burden. Limited life expectancy: de-intensify and focus on quality of life and symptom management.",
    6.65,6.3,6.3,0.92,C.muted,C.white);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 15  —  HYPOGLYCEMIA
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"HYPOGLYCEMIA","Hypoglycemia — Recognition, Classification & Management");

  // Classification table
  s.addText("ADA 2026 Hypoglycemia Classification",{x:0.3,y:1.1,w:6.1,h:0.38,fontSize:13,bold:true,color:C.navy,fontFace:"Calibri"});
  table(s,
    [["Level","Glucose","Clinical Significance"],
     ["Level 1 — Alert Value","< 70 mg/dL  (<3.9 mmol/L)","Requires action; no severe symptoms necessarily"],
     ["Level 2 — Clinically Significant","< 54 mg/dL  (<3.0 mmol/L)","Requires urgent treatment; serious hypoglycemia"],
     ["Level 3 — Severe","No specific BG threshold","Altered consciousness; requires assistance from another person"],
    ],
    null,[1.8,2.4,2.1],0.3,1.52,0.58,C.navy,C.slate);

  // Symptoms
  card(s,"Symptoms",
    "Neurogenic (autonomic): sweating, tremor, palpitations, hunger, anxiety, pallor\n\nNeuroglycopenic: confusion, slurred speech, weakness, visual changes, seizure, loss of consciousness",
    0.3,3.45,6.1,2.55,C.red,C.redLight);

  card(s,"Risk Factors for Hypoglycemia in T2DM",
    ["On sulfonylurea or insulin (especially basal+bolus)","Skipping or delaying meals","Increased exercise without dose adjustment",
     "Alcohol consumption (especially without food)","Renal impairment (↓ drug clearance)","Adrenal or pituitary insufficiency","Older age / cognitive impairment","Tight glycemic control"],
    0.3,6.13,6.1,1.1,C.navy,C.white);

  // Rule of 15
  card(s,"'Rule of 15' — Acute Treatment",
    ["1. Confirm BG <70 mg/dL (Level 1/2)","2. Take 15g fast-acting carbohydrate:\n   • 4 glucose tablets\n   • 4 oz (120 mL) fruit juice or regular soda\n   • 1 tablespoon honey or sugar",
     "3. Wait 15 minutes — recheck BG","4. Repeat if still <70 mg/dL","5. Once resolved — eat a full meal or snack to prevent recurrence"],
    6.65,1.1,6.3,3.15,C.teal,C.white);

  card(s,"Severe Hypoglycemia — Level 3",
    ["IM or SQ Glucagon 1 mg — train all caregivers","Nasal glucagon 3 mg — convenient; no reconstitution",
     "IV Dextrose (D50W) — if IV access available","Call 911 if no response to glucagon within 15 minutes",
     "After recovery: increase glucose target temporarily; review medication regimen"],
    6.65,4.4,6.3,2.2,C.red,C.redLight);

  card(s,"Prevention",
    "↓ or eliminate SU/meglitinide when adding GLP-1 RA or SGLT2i (Rec 9.17). CGM with low-glucose alerts. Educate on sick-day rules. Self-monitor before driving, exercise & bedtime.",
    6.65,6.75,6.3,0.55,C.navy,C.white);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 16  —  COMPLICATIONS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"COMPLICATIONS","Complications — Screening, Prevention & Treatment");

  // microvascular table
  s.addText("Microvascular Complications",{x:0.3,y:1.1,w:12.7,h:0.38,fontSize:13,bold:true,color:C.navy,fontFace:"Calibri"});
  table(s,
    [["Complication","Screening Method","Frequency","Prevention / Treatment"],
     ["Diabetic Retinopathy","Dilated fundus exam","Annually (q2yr if stable, no retinopathy)","Optimize A1C & BP; anti-VEGF for neovascular; laser photocoagulation"],
     ["Diabetic Kidney Disease","UACR + eGFR","Annually","ACEi/ARB; SGLT2i; GLP-1 RA; finerenone; BP <130/80; protein restrict if advanced"],
     ["Peripheral Neuropathy","10g monofilament + vibration + ABI","Annually","Optimize glycemia; TCAs, SNRIs, gabapentin/pregabalin, duloxetine for pain"],
     ["Autonomic Neuropathy","Clinical assessment","Annually","Glycemic control; gastroparesis: dietary modification + prokinetics"],
    ],
    null,[2.1,2.0,1.8,6.62],0.3,1.52,0.58,C.navy,C.slate);

  // macrovascular table
  s.addText("Macrovascular Complications",{x:0.3,y:4.62,w:12.7,h:0.38,fontSize:13,bold:true,color:C.teal,fontFace:"Calibri"});
  table(s,
    [["Complication","Screening / Assessment","Prevention","Treatment / Preferred Agents"],
     ["ASCVD (CAD, Stroke, PAD)","10-yr CV risk; symptoms; ECG","Statin + ACEi/ARB; aspirin (established CVD only)","GLP-1 RA (sema, lira, dula) or SGLT2i with proven MACE benefit"],
     ["Heart Failure","Echo; BNP if symptomatic","SGLT2i in high-risk patients","SGLT2i (dapa, empa) → ↓ HF hospitalization + CV death; avoid TZDs, sax/alo"],
     ["Peripheral Artery Disease","ABI if claudication or foot ulcer","Smoking cessation; BP/lipid control","GLP-1 RA (sema) — ↓ MACE including PAD events"],
    ],
    null,[2.1,2.3,2.4,5.72],0.3,5.04,0.54,C.teal,C.slate);

  s.addShape(prs.ShapeType.rect,{x:0.3,y:7.04,w:12.7,h:0.32,fill:{color:C.goldLight},line:{color:C.gold,width:0.4}});
  s.addText("Annual monitoring: retinopathy (dilated eye exam) + nephropathy (UACR + eGFR) + neuropathy (foot exam) + BP + lipids  |  Refer to ophthalmology, nephrology, podiatry as indicated",
    {x:0.4,y:7.05,w:12.5,h:0.3,fontSize:9,color:C.text,fontFace:"Calibri",valign:"middle"});
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 17  —  COMORBIDITY MANAGEMENT
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"COMORBIDITIES","Comorbidity & Cardiovascular Risk Management");

  card(s,"Hypertension — BP Target <130/80 mmHg (Section 10)",
    ["First-line: ACEi or ARB — especially if proteinuria/CKD/HF","Second-line: CCB or thiazide diuretic",
     "Avoid combining ACEi + ARB (↑ AKI risk)","Reassess BP at every clinical encounter",
     "Resistant HTN: add aldosterone antagonist (spironolactone); refer nephrology"],
    0.3,1.1,6.1,2.45,C.navy,C.white);

  card(s,"Dyslipidemia & Statin Therapy (Section 10)",
    ["LDL-C target: <70 mg/dL (established ASCVD); <100 mg/dL (high risk, no ASCVD)",
     "High-intensity statin first-line (atorvastatin 40–80mg; rosuvastatin 20–40mg)",
     "If LDL not at goal on max statin: add ezetimibe first, then PCSK9 inhibitor",
     "Triglycerides >500 mg/dL: fibrates or omega-3 to prevent pancreatitis",
     "Non-HDL-C target: <100 mg/dL (ASCVD); <130 mg/dL (no ASCVD)"],
    0.3,3.7,6.1,2.55,C.sky,C.white);

  card(s,"Antiplatelet Therapy",
    "Aspirin 75–100 mg/day: indicated for established ASCVD (secondary prevention).\nNOT routinely recommended for primary prevention (↑ bleeding risk outweighs benefit in most adults without established CVD).",
    0.3,6.4,6.1,0.95,C.muted,C.white);

  card(s,"CKD Management (Section 11)",
    ["ACEi or ARB: first-line for CKD + albuminuria — reduce proteinuria and CKD progression",
     "SGLT2i (eGFR >20): slows CKD progression — continue until dialysis or transplant",
     "GLP-1 RA: reduces albuminuria; semaglutide SQ first to show ↓ CKD hard endpoints",
     "Finerenone (non-steroidal MRA): ↓ CKD progression + CV events in T2DM+CKD+albuminuria",
     "Metformin: stop if eGFR <30; reduce dose if eGFR 30–45","BP target: <120/80 mmHg in CKD"],
    6.65,1.1,6.3,2.75,C.teal,C.white);

  card(s,"MASLD / Liver Disease",
    ["Screen with LFTs; elastography or biopsy if persistent LFT elevation",
     "GLP-1 RA (esp. semaglutide): benefit in NASH/MASLD (hepatic fat ↓)",
     "Pioglitazone: proven hepatic steatosis & inflammation benefit","Weight loss ≥7–10%: most effective intervention",
     "Avoid hepatotoxic agents; monitor LFTs on thiazolidinediones"],
    6.65,3.98,6.3,2.15,C.gold,C.goldLight);

  card(s,"Obstructive Sleep Apnea (OSA)",
    "OSA is common in T2DM (obesity, insulin resistance). Screening recommended. CPAP improves CV risk factors. Weight loss/GLP-1 RA/tirzepatide → OSA improvement.",
    6.65,6.28,6.3,1.0,C.navy,C.white);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 18  —  SPECIAL POPULATIONS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"SPECIAL POP.","Special Populations — T2DM Management");

  card(s,"Elderly & Frail Adults (Section 13)",
    ["A1C target: 7.5–8.0% (up to 8.5% if frail, dementia, limited life expectancy)",
     "Avoid hypoglycemia — prefer DPP-4i, low-dose GLP-1 RA over SU/insulin",
     "Avoid glibenclamide — prolonged severe hypoglycemia in elderly/CKD",
     "Simplify regimens; consider de-intensification","Screen cognitive function annually; adjust education approach","Fall risk: avoid agents causing orthostatic hypotension"],
    0.3,1.1,6.1,2.75,C.navy,C.white);

  card(s,"Obesity (Section 8)",
    ["First-line pharmacologic weight loss: GLP-1 RA or tirzepatide","Tirzepatide: up to ~22% body weight loss (highest of any approved agent)",
     "Metabolic surgery: BMI ≥40 or ≥35 with comorbidities — can achieve T2DM remission",
     "Avoid TZDs + insulin titration without weight-loss adjuncts","Re-evaluate glucose-lowering regimen after significant weight loss (de-intensify)"],
    0.3,3.98,6.1,2.2,C.gold,C.goldLight);

  card(s,"Heart Failure (Section 10)",
    ["SGLT2i (dapagliflozin, empagliflozin): reduce HF hospitalization + CV death in HFrEF and HFpEF",
     "AVOID in HF: saxagliptin, alogliptin (↑ HF hospitalization risk)","AVOID: TZDs (NYHA III/IV) — absolute CI",
     "GLP-1 RA: neutral on most HF outcomes; tirzepatide may benefit HFpEF (SUMMIT trial)"],
    6.65,1.1,6.3,2.35,C.teal,C.white);

  card(s,"Children & Adolescents (Section 14)",
    ["Screen after age 10 or onset of puberty if BMI ≥85th percentile + ≥1 RF",
     "First-line: metformin + lifestyle","FDA-approved for pediatric T2DM: liraglutide, empagliflozin, dapagliflozin",
     "A1C target: <7.0% (less stringent if hypoglycemia risk high)","T2DM in youth is more aggressive — earlier CV complications"],
    6.65,3.58,6.3,2.2,C.sky,C.white);

  card(s,"Pregnancy (Section 15)",
    ["Insulin: preferred agent — most safety data for glucose lowering","Metformin: crosses placenta — less preferred by ADA for T2DM in pregnancy",
     "GLP-1 RA, SGLT2i, DPP-4i: do NOT use in pregnancy (insufficient safety data)",
     "A1C target preconception: <6.0–6.5%","Screen GDM: 24–28 weeks with 75g OGTT (one-step) or two-step approach"],
    0.3,6.35,12.65,0.9,C.red,C.redLight);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 19  —  FOLLOW-UP SCHEDULE
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  chrome(s,"FOLLOW-UP","Follow-Up Schedule & Monitoring Plan");

  table(s,
    [["Parameter","Frequency","Target / Goal","Action if Abnormal"],
     ["A1C","q3 months (not at goal)\nq6 months (stable)","<7.0% (most adults)","Intensify therapy; reassess adherence"],
     ["Blood Pressure","Every visit","<130/80 mmHg","Add/intensify antihypertensive; ACEi/ARB first"],
     ["Weight / BMI","Every visit","≥5% loss (glycemic benefit)","Intensify lifestyle; GLP-1 RA/tirzepatide"],
     ["Fasting Lipids","Annually (more if abnormal)","LDL <70 mg/dL (ASCVD)","Intensify statin; add ezetimibe/PCSK9i"],
     ["eGFR + Serum Cr","Annually (more if CKD)","Monitor trajectory","Adjust medications; nephrology referral if eGFR <30"],
     ["UACR","Annually","<30 mg/g (goal)","ACEi/ARB; SGLT2i; recheck x2 if elevated"],
     ["Foot Exam","Annually (every visit if neuropathy)","No ulcer, no deformity","Podiatry referral; wound care; off-loading"],
     ["Dilated Eye Exam","Annually (q2yr if stable)","No retinopathy","Ophthalmology; anti-VEGF if neovascular"],
     ["Vitamin B12","Annually if metformin ≥4 yrs","Normal range","Supplement; B12 injection if severe deficiency"],
     ["Depression/Anxiety (PHQ-9)","Annually","PHQ-9 <5","Refer mental health; adjust DM management"],
    ],
    null,[2.0,1.9,2.1,5.9],0.28,1.1,0.54,C.navy,C.slate);

  // vaccines + referral
  card(s,"Immunizations (Section 4)",
    ["Influenza: annually","COVID-19: per current CDC recommendations",
     "Pneumococcal: PCV15/PCV20 + PPSV23 (<65); booster ≥65","Hepatitis B: unvaccinated adults <60 yrs","Zoster (Shingrix): age ≥50 yrs"],
    0.28,7.0,6.3,0.44,C.green,C.greenLight);

  card(s,"When to Refer",
    ["Endocrinology: A1C persistently >9% despite treatment; complex insulin; suspected monogenic DM | Ophthalmology: annual + any retinopathy | Nephrology: eGFR <30 | Cardiology: CVD/HF | Podiatry: ulcer/neuropathy | Dietitian: at diagnosis + annually"],
    6.62,7.0,6.7,0.44,C.teal,C.white);
}

// ═══════════════════════════════════════════════════════════════════════════
// SLIDE 20  —  KEY TAKEAWAYS
// ═══════════════════════════════════════════════════════════════════════════
{
  const s=prs.addSlide();
  titleSlide(s,"KEY TAKEAWAYS","ADA Standards of Care in Diabetes 2026");

  const pts=[
    ["1","DIAGNOSE","A1C ≥6.5% | FPG ≥126 | 2-h PG ≥200 | Random PG ≥200 + Sx. Confirm with 2 tests (no Sx crisis)."],
    ["2","CLASSIFY","Use AABBCC tool when T1 vs T2 unclear. Misclassification in up to 40% of adult-onset T1DM. Check islet Abs if uncertain."],
    ["3","START EARLY","Begin pharmacotherapy AT DIAGNOSIS — do not delay. Metformin + lifestyle is the foundation."],
    ["4","CARDIORENAL FIRST","ASCVD, HF, or CKD → GLP-1 RA or SGLT2i regardless of A1C. These agents provide cardiorenal protection beyond glucose lowering."],
    ["5","GLP-1 RA > INSULIN","GLP-1–based therapy preferred over insulin for most T2DM (Rec 9.21). If insulin needed, combine with GLP-1 RA (Rec 9.22)."],
    ["6","KNOW THE CIs","Metformin: eGFR <30. SGLT2i: T1DM, hold pre-surgery. GLP-1 RA: MTC/MEN-2. TZD: HF III/IV, bladder CA. SU: elderly/CKD."],
    ["7","INDIVIDUALIZE","A1C <7.0% for most. Relax to ≤8.0–8.5% in frail elderly, limited life expectancy, or recurrent severe hypoglycemia."],
    ["8","MONITOR YEARLY","A1C + BP + lipids + eGFR + UACR + foot exam + eye exam. Address weight, SDOH, DSMES, depression at every visit."],
  ];

  pts.forEach(([num,label,text],i)=>{
    const ry=1.62+i*0.68;
    s.addShape(prs.ShapeType.rect,{x:0.5,y:ry,w:12.3,h:0.6,fill:{color:i%2===0?"1B3F6E":"142F55"},line:{color:C.teal,width:0.5}});
    // number badge
    s.addShape(prs.ShapeType.rect,{x:0.5,y:ry,w:0.52,h:0.6,fill:{color:C.gold},line:{color:C.gold}});
    s.addText(num,{x:0.5,y:ry,w:0.52,h:0.6,fontSize:15,bold:true,color:C.navyDark,align:"center",valign:"middle",fontFace:"Calibri"});
    // label
    s.addShape(prs.ShapeType.rect,{x:1.07,y:ry,w:1.5,h:0.6,fill:{color:C.tealLight},line:{color:C.tealLight}});
    s.addText(label,{x:1.07,y:ry,w:1.5,h:0.6,fontSize:10,bold:true,color:C.white,align:"center",valign:"middle",fontFace:"Calibri"});
    // text
    s.addText(text,{x:2.68,y:ry,w:10.08,h:0.6,fontSize:11,color:C.white,fontFace:"Calibri",valign:"middle"});
  });
}

// ── WRITE ─────────────────────────────────────────────────────────────────────
prs.writeFile({fileName:"/home/daytona/workspace/t2dm-v2/T2DM_ADA2026_20Slides.pptx"})
  .then(()=>console.log("✅  T2DM_ADA2026_20Slides.pptx created successfully"))
  .catch(e=>console.error("❌ Error:",e));