import json
import subprocess
import base64
from io import BytesIO
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
import os

# ── Colour palette ──────────────────────────────────────────────
DARK_NAVY   = RGBColor(0x0D, 0x2B, 0x45)   # slide backgrounds / headers
MED_BLUE    = RGBColor(0x1A, 0x57, 0x8C)   # accent boxes
LIGHT_BLUE  = RGBColor(0xD6, 0xE8, 0xF7)   # content box backgrounds
ORANGE      = RGBColor(0xE8, 0x6A, 0x1A)   # highlight / key points
WHITE       = RGBColor(0xFF, 0xFF, 0xFF)
LIGHT_GRAY  = RGBColor(0xF2, 0xF5, 0xF9)
DARK_TEXT   = RGBColor(0x1A, 0x1A, 0x2E)
YELLOW_HL   = RGBColor(0xFF, 0xE0, 0x80)
GREEN       = RGBColor(0x17, 0x7E, 0x4E)
RED         = RGBColor(0xC0, 0x39, 0x2B)

prs = Presentation()
prs.slide_width  = Inches(13.333)
prs.slide_height = Inches(7.5)
blank_layout = prs.slide_layouts[6]   # fully blank

# ── Helper utilities ────────────────────────────────────────────
def add_rect(slide, x, y, w, h, fill_rgb, alpha=None):
    shape = slide.shapes.add_shape(1, Inches(x), Inches(y), Inches(w), Inches(h))
    shape.line.fill.background()
    shape.fill.solid()
    shape.fill.fore_color.rgb = fill_rgb
    return shape

def add_text(slide, text, x, y, w, h,
             font_size=18, bold=False, italic=False, color=WHITE,
             align=PP_ALIGN.LEFT, v_anchor=MSO_ANCHOR.TOP, wrap=True,
             font_name="Calibri"):
    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 = Inches(0.05)
    tf.margin_right = Inches(0.05)
    tf.margin_top = Inches(0.03)
    tf.margin_bottom = Inches(0.03)
    p = tf.paragraphs[0]
    p.alignment = align
    run = p.add_run()
    run.text = text
    run.font.name = font_name
    run.font.size = Pt(font_size)
    run.font.bold = bold
    run.font.italic = italic
    run.font.color.rgb = color
    return tb

def add_multi_bullet(slide, items, x, y, w, h,
                     font_size=15, color=DARK_TEXT, bold_first=False,
                     bullet_char="▸ ", line_spacing=1.2):
    """items = list of (indent_level, text, bold) tuples or plain strings."""
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame
    tf.word_wrap = True
    tf.vertical_anchor = MSO_ANCHOR.TOP
    tf.margin_left = Inches(0.1)
    tf.margin_right = Inches(0.05)
    tf.margin_top = Inches(0.05)
    tf.margin_bottom = Inches(0.05)

    first = True
    for item in items:
        if isinstance(item, str):
            lvl, text, bold = 0, item, False
        else:
            lvl, text, bold = item

        if first:
            p = tf.paragraphs[0]
            first = False
        else:
            p = tf.add_paragraph()

        p.space_before = Pt(2)
        p.space_after  = Pt(1)
        indent_str = "    " * lvl
        run = p.add_run()
        run.text = indent_str + bullet_char + text
        run.font.name = "Calibri"
        run.font.size = Pt(font_size)
        run.font.bold = bold
        run.font.color.rgb = color
    return tb

def slide_header(slide, title, subtitle=None,
                 bg_color=DARK_NAVY, title_color=WHITE, sub_color=YELLOW_HL):
    """Full-width dark header bar at top."""
    bar_h = 1.0 if subtitle else 0.85
    add_rect(slide, 0, 0, 13.333, bar_h, bg_color)
    add_text(slide, title, 0.25, 0.05, 12.8, 0.65,
             font_size=28, bold=True, color=title_color,
             align=PP_ALIGN.LEFT, v_anchor=MSO_ANCHOR.MIDDLE)
    if subtitle:
        add_text(slide, subtitle, 0.25, 0.65, 12.8, 0.35,
                 font_size=14, italic=True, color=sub_color,
                 align=PP_ALIGN.LEFT)

def section_box(slide, title, x, y, w, h,
                title_color=WHITE, box_color=MED_BLUE, content_color=LIGHT_BLUE):
    """Coloured section header + lighter content area."""
    add_rect(slide, x, y, w, 0.38, box_color)
    add_text(slide, title, x+0.1, y+0.02, w-0.2, 0.34,
             font_size=14, bold=True, color=title_color,
             align=PP_ALIGN.LEFT, v_anchor=MSO_ANCHOR.MIDDLE)
    add_rect(slide, x, y+0.38, w, h-0.38, content_color)

def fetch_img(url):
    try:
        result = json.loads(subprocess.check_output(
            ["python", "/tmp/skills/shared/scripts/fetch_images.py", url],
            timeout=30
        ))
        if result and result[0].get("base64"):
            b64 = result[0]["base64"]
            if "," in b64:
                b64 = b64.split(",", 1)[1]
            return BytesIO(base64.b64decode(b64))
    except Exception as e:
        print(f"  Image fetch failed for {url}: {e}")
    return None

def add_image(slide, url, x, y, w, h=None):
    img_io = fetch_img(url)
    if img_io:
        try:
            if h:
                pic = slide.shapes.add_picture(img_io, Inches(x), Inches(y),
                                               width=Inches(w), height=Inches(h))
            else:
                pic = slide.shapes.add_picture(img_io, Inches(x), Inches(y), width=Inches(w))
            return pic
        except Exception as e:
            print(f"  Could not embed image: {e}")
    return None

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 1  – Title slide
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, DARK_NAVY)
# Decorative accent stripe
add_rect(s, 0, 3.5, 13.333, 0.08, ORANGE)
add_rect(s, 0, 3.58, 13.333, 0.04, MED_BLUE)

add_text(s, "PEPTIC ULCER DISEASE",
         0.8, 1.2, 11.8, 1.8,
         font_size=48, bold=True, color=WHITE,
         align=PP_ALIGN.CENTER, v_anchor=MSO_ANCHOR.MIDDLE)
add_text(s, "A Comprehensive Postgraduate Review",
         0.8, 2.85, 11.8, 0.7,
         font_size=22, italic=True, color=YELLOW_HL,
         align=PP_ALIGN.CENTER)
add_text(s, "Department of Internal Medicine  |  Postgraduate Teaching Series",
         0.8, 3.85, 11.8, 0.5,
         font_size=16, color=LIGHT_BLUE, align=PP_ALIGN.CENTER)
add_text(s, "Sources: Schwartz's Surgery 11e · Sleisenger & Fordtran 11e · Bailey & Love 28e\n"
            "Robbins & Kumar Basic Pathology · Yamada's Gastroenterology 7e",
         0.8, 6.5, 11.8, 0.7,
         font_size=11, italic=True, color=RGBColor(0xAA, 0xBB, 0xCC),
         align=PP_ALIGN.CENTER)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 2  – Table of Contents / Lecture Outline
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Lecture Outline", "What we will cover today")

topics_left = [
    "1. Definition & Historical Perspective",
    "2. Epidemiology & Burden of Disease",
    "3. Anatomy & Pathology",
    "4. Pathophysiology – Mucosal Balance",
    "5. Aetiology – H. pylori",
    "6. Aetiology – NSAIDs",
    "7. Other Risk Factors",
]
topics_right = [
    "8. Clinical Presentation & Symptoms",
    "9. Investigations & Diagnosis",
    "10. Complications – Bleeding",
    "11. Complications – Perforation",
    "12. Complications – Obstruction",
    "13. Medical Management",
    "14. H. pylori Eradication Regimens",
    "15. Surgical Management",
    "16. Special Situations & Follow-up",
]
add_rect(s, 0.4, 1.05, 6.0, len(topics_left)*0.5+0.2, MED_BLUE)
for i, t in enumerate(topics_left):
    add_text(s, t, 0.55, 1.1 + i*0.5, 5.7, 0.48,
             font_size=15, color=WHITE, v_anchor=MSO_ANCHOR.MIDDLE)

add_rect(s, 6.8, 1.05, 6.1, len(topics_right)*0.5+0.2, DARK_NAVY)
for i, t in enumerate(topics_right):
    add_text(s, t, 6.95, 1.1 + i*0.5, 5.8, 0.48,
             font_size=15, color=WHITE, v_anchor=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 3  – Definition & Historical Background
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Definition & Historical Background")

add_rect(s, 0.4, 1.1, 12.5, 1.8, WHITE)
add_rect(s, 0.4, 1.1, 0.08, 1.8, ORANGE)
add_text(s, "Definition",
         0.6, 1.12, 12.0, 0.45, font_size=15, bold=True, color=DARK_NAVY)
add_text(s,
    "Peptic Ulcer Disease (PUD) is a breach in the mucosal lining of the gastrointestinal tract extending "
    "through the muscularis mucosae into the submucosa or deeper, occurring in areas exposed to acid "
    "and pepsin — most commonly the gastric antrum and first portion of the duodenum.",
    0.6, 1.58, 12.0, 1.3, font_size=15, color=DARK_TEXT, wrap=True)

add_rect(s, 0.4, 3.1, 12.5, 3.8, WHITE)
add_rect(s, 0.4, 3.1, 0.08, 3.8, MED_BLUE)
add_text(s, "Historical Milestones", 0.6, 3.12, 11.0, 0.45,
         font_size=15, bold=True, color=DARK_NAVY)
hist = [
    (0, "1800s: Peptic ulcer recognised as a distinct clinical entity; acid implicated", False),
    (0, "1910: Schwartz popularises 'no acid, no ulcer' dictum", False),
    (0, "1938: Mann & Williamson: vagotomy shown to reduce acid and heal ulcers", False),
    (0, "1976: Introduction of H2-receptor antagonists (cimetidine) — first major medical therapy", False),
    (0, "1983: Barry Marshall & Robin Warren identify Helicobacter pylori — Nobel Prize 2005", False),
    (0, "1989: Proton pump inhibitors (omeprazole) introduced — paradigm shift in acid suppression", False),
    (0, "1990s–present: H. pylori eradication transforms PUD from chronic relapsing to curable disease", False),
]
add_multi_bullet(s, hist, 0.6, 3.6, 12.0, 3.2, font_size=14, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 4  – Epidemiology
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Epidemiology & Burden of Disease",
             "Global prevalence, trends, and risk demographics")

# Left column
section_box(s, "Global Burden", 0.4, 1.05, 6.0, 3.4)
epi_left = [
    "Lifetime risk: ~10% males, ~4% females (USA)",
    "~4 million individuals treated annually in the USA",
    "~100,000 hospitalisations/year for bleeding PUD",
    "DU more common than GU (4:1 ratio)",
    "Peak incidence shifting to older age groups",
    "Gender gap narrowing — hormonal/lifestyle factors",
    "Rising incidence in resource-poor nations",
]
add_multi_bullet(s, epi_left, 0.55, 1.5, 5.7, 2.8, font_size=13, color=DARK_TEXT)

section_box(s, "Temporal Trends", 6.7, 1.05, 6.2, 3.4)
epi_right = [
    "Marked decline in elective surgery since 1990s",
    "Reduction in DU incidence correlates with ↓ H. pylori",
    "Increasing GU: driven by aging + NSAID/aspirin use",
    "Emergency surgery for complications persists",
    "30-day mortality: bleeding ulcer ~5–10%",
    "Mortality higher in elderly and those with comorbidities",
]
add_multi_bullet(s, epi_right, 6.85, 1.5, 5.9, 2.8, font_size=13, color=DARK_TEXT)

# Key stat boxes
add_rect(s, 0.4, 4.55, 3.8, 1.4, ORANGE)
add_text(s, "70–90%", 0.4, 4.58, 3.8, 0.7, font_size=36, bold=True,
         color=WHITE, align=PP_ALIGN.CENTER)
add_text(s, "of DU associated\nwith H. pylori", 0.4, 5.2, 3.8, 0.7,
         font_size=14, color=WHITE, align=PP_ALIGN.CENTER)

add_rect(s, 4.5, 4.55, 3.8, 1.4, MED_BLUE)
add_text(s, "50–60%", 4.5, 4.58, 3.8, 0.7, font_size=36, bold=True,
         color=WHITE, align=PP_ALIGN.CENTER)
add_text(s, "of GU associated\nwith NSAIDs", 4.5, 5.2, 3.8, 0.7,
         font_size=14, color=WHITE, align=PP_ALIGN.CENTER)

add_rect(s, 8.6, 4.55, 4.3, 1.4, GREEN)
add_text(s, "~5–10%", 8.6, 4.58, 4.3, 0.7, font_size=36, bold=True,
         color=WHITE, align=PP_ALIGN.CENTER)
add_text(s, "30-day mortality\nin bleeding PUD", 8.6, 5.2, 4.3, 0.7,
         font_size=14, color=WHITE, align=PP_ALIGN.CENTER)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 5  – Anatomy & Sites
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Anatomy & Common Sites of Ulceration")

add_rect(s, 0.4, 1.05, 8.0, 5.9, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 5.9, MED_BLUE)
add_text(s, "Common Sites", 0.6, 1.08, 7.6, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
sites = [
    (0, "DUODENUM (most common): First part (D1) — 95% of duodenal ulcers", True),
    (1, "Anterior wall: tend to PERFORATE", False),
    (1, "Posterior wall: tend to BLEED (erosion of gastroduodenal artery)", False),
    (1, "\"Kissing ulcers\": simultaneous anterior + posterior", False),
    (0, "STOMACH:", True),
    (1, "Lesser curve (most common gastric site)", False),
    (1, "Gastric antrum (prepyloric)", False),
    (1, "Gastric body", False),
    (1, "Cardia/GOJ — increasing incidence (exclude malignancy)", False),
    (0, "UNCOMMON / SPECIAL SITES:", True),
    (1, "Oesophagus — GERD-related / Barrett's ulcer", False),
    (1, "Stomal ulcer — post gastroenterostomy or Billroth II (jejunal side)", False),
    (1, "Meckel's diverticulum — ectopic gastric mucosa", False),
    (1, "Jejunum — Zollinger–Ellison syndrome (ZES)", False),
    (0, "Key rule: Ulcer forms at junction between different epithelial types — least acid-resistant tissue", False),
]
add_multi_bullet(s, sites, 0.6, 1.55, 7.7, 5.3, font_size=13, color=DARK_TEXT)

# Right side: Johnson classification of gastric ulcers
add_rect(s, 8.7, 1.05, 4.2, 5.9, DARK_NAVY)
add_text(s, "Johnson Classification\nof Gastric Ulcers", 8.85, 1.08, 4.0, 0.8,
         font_size=14, bold=True, color=YELLOW_HL, align=PP_ALIGN.CENTER)
johnson = [
    "Type I: Lesser curve, body\n(↓ acid, mucosal defect)",
    "Type II: Gastric body +\nduodenal ulcer (↑ acid)",
    "Type III: Prepyloric\n(↑ acid, like DU)",
    "Type IV: High on lesser\ncurve near GOJ",
    "Type V: Any site\n(NSAID-induced)",
]
colors_j = [WHITE, YELLOW_HL, WHITE, YELLOW_HL, WHITE]
for i, (jt, jc) in enumerate(zip(johnson, colors_j)):
    ypos = 2.05 + i * 0.9
    add_rect(s, 8.85, ypos, 3.9, 0.82, MED_BLUE if i%2==0 else RGBColor(0x14, 0x45, 0x70))
    add_text(s, jt, 8.95, ypos+0.03, 3.7, 0.78,
             font_size=12, color=jc, v_anchor=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 6  – Pathophysiology
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Pathophysiology",
             "The balance between aggressive & defensive forces")

# Balance diagram
add_rect(s, 0.4, 1.1, 5.8, 2.9, RED)
add_text(s, "⚠  AGGRESSIVE FACTORS", 0.5, 1.12, 5.6, 0.5,
         font_size=16, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
aggressive = [
    "Hydrochloric acid (HCl) — parietal cells",
    "Pepsin — chief cells (requires acid activation)",
    "H. pylori — ammonia, proteases, cytotoxins",
    "NSAIDs — direct and indirect injury",
    "Bile reflux",
    "Alcohol, tobacco",
]
add_multi_bullet(s, aggressive, 0.5, 1.65, 5.6, 2.2, font_size=13, color=WHITE)

add_rect(s, 7.1, 1.1, 5.8, 2.9, GREEN)
add_text(s, "🛡  DEFENSIVE FACTORS", 7.2, 1.12, 5.6, 0.5,
         font_size=16, bold=True, color=WHITE, align=PP_ALIGN.CENTER)
defensive = [
    "Mucous layer — bicarbonate-rich gel",
    "Epithelial tight junctions — barrier function",
    "Mucosal blood flow — delivers O₂, buffers H⁺",
    "Prostaglandins E₂ & I₂ — stimulate mucus/bicarb",
    "Epithelial restitution — rapid surface repair",
    "Growth factors (EGF, TGF-α)",
]
add_multi_bullet(s, defensive, 7.2, 1.65, 5.6, 2.2, font_size=13, color=WHITE)

# Equation
add_rect(s, 0.4, 4.1, 12.5, 0.5, ORANGE)
add_text(s,
    "ULCER  =  Aggressive Factors  >  Defensive Factors  (imbalance in either direction causes mucosal breakdown)",
    0.5, 4.12, 12.3, 0.44, font_size=14, bold=True, color=WHITE, align=PP_ALIGN.CENTER,
    v_anchor=MSO_ANCHOR.MIDDLE)

add_rect(s, 0.4, 4.7, 12.5, 2.65, WHITE)
add_rect(s, 0.4, 4.7, 0.08, 2.65, ORANGE)
add_text(s, "Acid Secretion Physiology (key for pharmacology)", 0.6, 4.72, 12.0, 0.42,
         font_size=14, bold=True, color=DARK_NAVY)
phys = [
    "Parietal cell stimulants: Gastrin (G-cells, antrum), ACh (vagal), Histamine (ECL cells) → activate H⁺/K⁺-ATPase pump",
    "Gastrin release: stimulated by protein, distension, vagal tone; inhibited by low antral pH via somatostatin (D cells)",
    "H. pylori depletes antral somatostatin → ↑ gastrin → ↑ acid → parietal cell hyperplasia (DU pathway)",
    "Zollinger-Ellison syndrome: gastrin-secreting tumour → massive acid → multiple/atypical ulcers",
    "NSAIDs: inhibit COX-1 → ↓ prostaglandins → ↓ mucus/bicarb/blood flow; also direct mucosal topical injury",
]
add_multi_bullet(s, phys, 0.6, 5.15, 12.0, 2.1, font_size=12.5, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 7  – H. pylori Aetiology
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "H. pylori — The Primary Causative Agent",
             "Discovered 1983 · Nobel Prize 2005 · Transforms PUD natural history")

add_rect(s, 0.4, 1.05, 7.8, 6.3, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 6.3, MED_BLUE)
add_text(s, "Key Facts About H. pylori", 0.6, 1.08, 7.5, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
hp = [
    (0, "Gram-negative, spiral-shaped, flagellated microaerophilic rod", False),
    (0, "Colonises gastric antrum preferentially; survives by urease-mediated NH₃ production → neutralises acid", False),
    (0, "Infects >50% of the world's population; higher in developing countries (>80%)", False),
    (0, "Transmission: faeco-oral, oral-oral; childhood acquisition most common", False),
    (0, "Virulence factors:", True),
    (1, "Urease → NH₃ → mucosal injury + alkalinises microenvironment", False),
    (1, "CagA (cytotoxin-associated gene A) — injected via T4SS, disrupts cell signalling, ↑ cancer risk", False),
    (1, "VacA (vacuolating cytotoxin A) — induces vacuolation, apoptosis, immune evasion", False),
    (1, "OipA, BabA — outer membrane proteins, adhesion", False),
    (0, "Mechanism in DU: antral gastritis → ↓ somatostatin D cells → ↑ gastrin → ↑ parietal cell mass → hyperacidity → duodenal gastric metaplasia → H. pylori colonises duodenum → ↑ DU risk 50-fold", False),
    (0, "90% of DU patients are H. pylori positive", False),
    (0, "70% of GU patients are H. pylori positive", False),
    (0, "Curing H. pylori: reduces ulcer recurrence from >75% → <20% (multiple RCTs)", False),
    (0, "Association: low-grade gastric MALT lymphoma, gastric adenocarcinoma (Class I carcinogen)", False),
]
add_multi_bullet(s, hp, 0.6, 1.55, 7.6, 5.7, font_size=12.5, color=DARK_TEXT)

# Right: image placeholder + diagnosis panel
add_image(s,
    "https://cdn.orris.care/cdss_images/Pathology_1760047119073_99ab0840-08f9-4a89-92d7-23c5c6144c82.jpg",
    8.45, 1.05, 4.5, 3.0)
add_text(s, "H. pylori-associated chronic active gastritis\n(H&E — dense lymphoplasmacytic infiltrate)",
         8.45, 4.1, 4.5, 0.6, font_size=10, italic=True, color=DARK_TEXT, align=PP_ALIGN.CENTER)

add_rect(s, 8.45, 4.75, 4.5, 2.6, DARK_NAVY)
add_text(s, "Testing for H. pylori", 8.55, 4.78, 4.3, 0.42,
         font_size=14, bold=True, color=YELLOW_HL)
tests = [
    "NON-INVASIVE:",
    "• Urea Breath Test (UBT) — best accuracy",
    "• Stool antigen test (SAT) — cost-effective",
    "• Serology (IgG) — cannot confirm active",
    "INVASIVE (endoscopy):",
    "• Rapid urease test (CLO test)",
    "• Histology ± Giemsa stain",
    "• Culture (for resistance testing)",
]
y_off = 5.22
for t in tests:
    bld = ":" in t and not t.startswith("•")
    add_text(s, t, 8.55, y_off, 4.3, 0.34,
             font_size=11, bold=bld, color=WHITE if not bld else YELLOW_HL)
    y_off += 0.3

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 8  – NSAIDs
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "NSAIDs & Aspirin — Second Major Cause",
             "Mechanism · Risk stratification · Prevention strategies")

add_rect(s, 0.4, 1.05, 7.9, 6.35, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 6.35, RED)
add_text(s, "NSAID-Induced Mucosal Injury", 0.6, 1.08, 7.6, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
nsaid = [
    (0, "MECHANISM — Dual injury:", True),
    (1, "Systemic: COX-1 inhibition → ↓ PGE₂, PGI₂ → ↓ mucus, bicarb, mucosal blood flow", False),
    (1, "Topical: direct epithelial injury (weakly acidic, accumulate in cells, uncouple oxidative phosphorylation)", False),
    (0, "All NSAIDs (incl. low-dose aspirin) increase GI risk; selectivity varies:", True),
    (1, "Traditional NSAIDs (e.g. ibuprofen, naproxen, diclofenac) — high risk", False),
    (1, "COX-2 selective (e.g. celecoxib) — lower GI risk but ↑ CV risk", False),
    (1, "Low-dose aspirin — still carries significant GI risk even at 75–150 mg/day", False),
    (0, "GI risk factors for NSAID users:", True),
    (1, "Age >65, prior PUD/GI bleed, H. pylori co-infection", False),
    (1, "Concomitant corticosteroids, anticoagulants, dual antiplatelet therapy", False),
    (1, "High-dose or multiple NSAIDs", False),
    (0, "Prevention strategies:", True),
    (1, "Use lowest effective dose for shortest duration", False),
    (1, "Co-prescribe PPI (preferred) or misoprostol in high-risk patients", False),
    (1, "Test and treat H. pylori before starting long-term NSAIDs", False),
    (1, "Switch to COX-2 selective agent where CV risk permits", False),
    (0, "MUCOSA trial: misoprostol ↓ complicated UGI events by 53% vs NSAID alone", False),
    (0, "VIGOR trial: rofecoxib ↓ GI events by 54% vs naproxen", False),
]
add_multi_bullet(s, nsaid, 0.6, 1.55, 7.7, 5.7, font_size=12, color=DARK_TEXT)

# Right column
add_rect(s, 8.6, 1.05, 4.35, 3.0, DARK_NAVY)
add_text(s, "Risk Stratification\n(GI Risk × CV Risk Matrix)",
         8.75, 1.08, 4.1, 0.65, font_size=14, bold=True, color=YELLOW_HL)
matrix = [
    ("LOW GI risk", "LOW CV", "NSAID alone"),
    ("LOW GI risk", "HIGH CV", "Naproxen + PPI"),
    ("HIGH GI risk", "LOW CV", "COX-2 + PPI"),
    ("HIGH GI risk", "HIGH CV", "Avoid NSAIDs\nif possible"),
]
for i, (gi, cv, rx) in enumerate(matrix):
    yp = 1.82 + i*0.52
    add_rect(s, 8.6, yp, 4.35, 0.5, MED_BLUE if i%2==0 else RGBColor(0x0D,0x2B,0x45))
    add_text(s, f"{gi} / {cv} → {rx}", 8.72, yp+0.04, 4.1, 0.44,
             font_size=11, color=WHITE, v_anchor=MSO_ANCHOR.MIDDLE)

add_rect(s, 8.6, 4.15, 4.35, 3.2, WHITE)
add_rect(s, 8.6, 4.15, 0.08, 3.2, ORANGE)
add_text(s, "Indications for H. pylori\nTest & Treat with NSAIDs",
         8.75, 4.17, 4.1, 0.65, font_size=13, bold=True, color=DARK_NAVY)
ind = [
    "Test before starting chronic NSAIDs",
    "Prior history of PUD",
    "Dyspepsia on NSAIDs",
    "After NSAID-related GI bleed",
    "Eradicate before initiating therapy",
]
add_multi_bullet(s, ind, 8.75, 4.85, 4.1, 2.4, font_size=12, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 9  – Other Risk Factors
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Additional Risk Factors & Special Causes")

boxes = [
    ("Zollinger–Ellison Syndrome",
     ["Gastrin-secreting tumour (gastrinoma)", "Multiple, atypical ulcers (distal duodenum/jejunum)", "Suspect: H. pylori-neg, NSAID-neg ulcer; diarrhoea; MEN-1",
      "Diagnosis: fasting serum gastrin >1000 pg/mL + secretin stimulation test", "CT/MRI + somatostatin receptor scintigraphy for tumour localisation",
      "Treatment: high-dose PPI; surgical resection if localised"], MED_BLUE),
    ("Cigarette Smoking",
     ["↓ mucosal prostaglandin synthesis", "↑ gastric acid secretion; ↓ duodenal bicarb",
      "↓ mucosal blood flow — impairs healing", "Doubles ulcer risk; ↑ recurrence rate",
      "Delays healing even on PPI/eradication therapy"], DARK_NAVY),
    ("Systemic Diseases",
     ["Alcoholic cirrhosis — ↑ portal hypertension, ↓ hepatic clearance of gastrin",
      "COPD — hypoxia ↓ mucosal blood flow", "Chronic renal failure — ↑ gastrin (↓ renal clearance)",
      "Hyperparathyroidism — hypercalcaemia stimulates gastrin secretion",
      "Stress ulcers: critically ill patients (Cushing — CNS; Curling — burns)"], GREEN),
    ("Genetics & Other",
     ["Blood group O — receptor affinity for H. pylori adhesins", "MEN-1 syndrome — ZES component",
      "Rare: Crohn's disease, viral (CMV, HSV) in immunocompromised",
      "Psychological stress: probably permissive rather than causative",
      "Corticosteroids alone: low risk; synergistic with NSAIDs — high risk"], ORANGE),
]

positions = [(0.4, 1.05), (6.8, 1.05), (0.4, 4.25), (6.8, 4.25)]
for (bx, by), (title, items, col) in zip(positions, boxes):
    add_rect(s, bx, by, 6.0, 0.42, col)
    add_text(s, title, bx+0.1, by+0.03, 5.8, 0.36,
             font_size=14, bold=True, color=WHITE, v_anchor=MSO_ANCHOR.MIDDLE)
    add_rect(s, bx, by+0.42, 6.0, 2.9, WHITE)
    add_multi_bullet(s, items, bx+0.15, by+0.48, 5.75, 2.8, font_size=12, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 10  – Clinical Presentation
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Clinical Presentation",
             "Symptoms are often indistinguishable between gastric and duodenal ulcers")

add_rect(s, 0.4, 1.05, 8.0, 5.9, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 5.9, MED_BLUE)
add_text(s, "Symptoms & Signs", 0.6, 1.08, 7.7, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
sx = [
    (0, "PAIN (most prominent feature):", True),
    (1, "Epigastric pain — gnawing, burning, or aching in character", False),
    (1, "Radiation to back — suggests penetrating posterior DU (gastroduodenal artery)", False),
    (1, "DU classically: pain 2–3 h post-meal, relieved by food/antacids ('hunger pain')", False),
    (1, "GU classically: pain precipitated by food ('food fear'), weight loss more prominent", False),
    (1, "However: symptoms CANNOT reliably distinguish GU from DU", False),
    (1, "Periodicity: symptoms disappear for weeks/months, then recur (healing/relapse cycle)", False),
    (0, "VOMITING:", True),
    (1, "Not a prominent feature unless gastric outlet obstruction has developed", False),
    (1, "Projectile/bile-free vomiting + succussion splash → GOO", False),
    (0, "OTHER SYMPTOMS:", True),
    (1, "Weight loss: more common in GU (food fear); also in malignancy — biopsy all GU", False),
    (1, "Anaemia: chronic occult bleeding (microcytic, iron-deficiency)", False),
    (1, "Haematemesis / melaena: suggests acute upper GI bleeding", False),
    (0, "EXAMINATION:", True),
    (1, "Epigastric tenderness — mild; percussion tenderness", False),
    (1, "Rigid abdomen + absent bowel sounds → perforation", False),
    (1, "Succussion splash (late GOO)", False),
    (1, "Pallor (anaemia), tachycardia/hypotension (haemorrhage)", False),
]
add_multi_bullet(s, sx, 0.6, 1.55, 7.7, 5.3, font_size=12.5, color=DARK_TEXT)

add_rect(s, 8.7, 1.05, 4.2, 5.9, DARK_NAVY)
add_text(s, "Important Differentials", 8.85, 1.08, 4.0, 0.42,
         font_size=14, bold=True, color=YELLOW_HL)
diffs = [
    "Gastric cancer *",
    "GERD",
    "Functional dyspepsia",
    "Acute pancreatitis",
    "Biliary colic",
    "Gastric volvulus",
    "Ischaemic gut",
    "Aortic aneurysm",
    "Lower lobe pneumonia",
    "",
    "* ALL gastric ulcers must",
    "  have biopsies taken to",
    "  exclude malignancy",
]
y = 1.57
for d in diffs:
    col = YELLOW_HL if d.startswith("*") else WHITE
    add_text(s, d, 8.85, y, 3.9, 0.4,
             font_size=12, color=col, bold=d.startswith("*"))
    y += 0.4

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 11  – Investigations & Diagnosis
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Investigations & Diagnosis",
             "Endoscopy is gold standard · Always biopsy gastric ulcers")

section_box(s, "Upper GI Endoscopy (Gold Standard)", 0.4, 1.05, 8.2, 3.5)
endo = [
    "Visualises mucosal defect directly; allows biopsy, CLO test, therapeutic intervention",
    "GASTRIC ULCERS: ≥6–8 biopsies from ulcer edge (not base) — exclude malignancy",
    "'U' manoeuvre essential: inspect incisura, lesser curve, GOJ",
    "DUODENAL ULCERS: biopsy only if atypical or if malignancy suspected",
    "CLO (Campylobacter-like organism) test: rapid urease test for H. pylori — sensitivity ~90%",
    "Antral biopsy for histology ± Giemsa/modified Giemsa stain for H. pylori",
    "Must confirm healing of ALL gastric ulcers at 6–8 weeks (repeat endoscopy)",
]
add_multi_bullet(s, endo, 0.55, 1.5, 7.9, 2.9, font_size=12.5, color=DARK_TEXT)

section_box(s, "H. pylori Testing Summary", 0.4, 4.65, 8.2, 2.7)
htest = [
    "UBT (Urea Breath Test): BEST for confirming eradication; stop PPI 2 weeks, antibiotics 4 weeks before",
    "Stool Antigen Test (SAT): useful pre- and post-treatment; avoid PPIs 2 weeks before",
    "Serology (IgG): cheap, not affected by PPIs/antibiotics; CANNOT confirm active infection or eradication",
    "False negatives: recent PPI/antibiotics, active GI bleeding → use serology or histology in acute bleed",
]
add_multi_bullet(s, htest, 0.55, 5.1, 7.9, 2.1, font_size=12.5, color=DARK_TEXT)

# Right side
add_rect(s, 8.85, 1.05, 4.05, 6.3, WHITE)
add_rect(s, 8.85, 1.05, 0.08, 6.3, ORANGE)
add_text(s, "Other Investigations", 9.05, 1.08, 3.8, 0.42,
         font_size=14, bold=True, color=DARK_NAVY)
other = [
    "BLOODS:",
    "  FBC — anaemia (iron deficiency)",
    "  U&E — electrolyte disturbance (GOO: hypochloraemic hypokalaemic alkalosis)",
    "  LFTs, coagulation — if bleeding",
    "  Fasting serum gastrin — if ZES suspected (>1000 pg/mL highly suggestive)",
    "  Calcium — rule out hyperparathyroidism",
    "",
    "RADIOLOGY:",
    "  Barium meal: 'niche' sign (GU), clover-leaf deformity (DU); now largely replaced by endoscopy",
    "  CT scan: investigation of choice for suspected perforation (free air / fluid)",
    "  CT/MRI + somatostatin scintigraphy: localise gastrinoma in ZES",
    "  Erect CXR: free air under diaphragm in perforation",
    "",
    "SECRETIN STIMULATION TEST:",
    "  ZES: paradoxical ↑ gastrin after IV secretin",
]
y_off = 1.55
for line in other:
    bld = line.endswith(":") and not line.startswith(" ")
    col = MED_BLUE if bld else DARK_TEXT
    add_text(s, line, 9.05, y_off, 3.7, 0.36,
             font_size=11, bold=bld, color=col)
    y_off += 0.36 if not line == "" else 0.2

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 12  – Endoscopic image slide
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, DARK_NAVY)
slide_header(s, "Endoscopic Appearance — PUD", "Educational imaging",
             bg_color=MED_BLUE, sub_color=WHITE)

add_image(s,
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_644f5d01a41988a6473fda233160bb2f0d93f04cd79693ee2f1889ab37d1e08c.jpg",
    0.4, 1.1, 5.9, 4.2)
add_text(s, "Large posterior duodenal bulb ulcer\nActive stage A1 (Sakita-Miwa classification)\nFibrinoid base; surrounding oedematous mucosa",
         0.4, 5.35, 5.9, 1.1, font_size=13, italic=True, color=LIGHT_BLUE,
         align=PP_ALIGN.CENTER)

add_image(s,
    "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_2445e0fa69d758eff88db95e8f9adf6bc96dcc27fd1a0cd2e7b8e264caff293f.jpg",
    6.6, 1.1, 6.3, 4.2)
add_text(s, "Composite panel: H. pylori-associated gastritis & PUD\nNodular gastritis, duodenal and gastric ulcers, erosions",
         6.6, 5.35, 6.3, 1.1, font_size=13, italic=True, color=LIGHT_BLUE,
         align=PP_ALIGN.CENTER)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 13  – Complications: GI Bleeding
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Complications — Upper GI Bleeding",
             "Most common and most lethal complication of PUD")

add_rect(s, 0.4, 1.05, 8.5, 6.35, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 6.35, RED)
add_text(s, "Bleeding Peptic Ulcer", 0.6, 1.08, 8.2, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
bleed = [
    (0, "50% of all UGI bleeds; ~100,000 hospitalisations/year in USA", False),
    (0, "Posterior DU → erodes GASTRODUODENAL ARTERY (GDA) — major vessel bleed", False),
    (0, "3/4 of patients stop bleeding spontaneously with acid suppression + nil by mouth", False),
    (0, "1/4 continue or REBLEED — this group accounts for virtually ALL morbidity/mortality", False),
    (0, "High-risk endoscopic stigmata (Forrest Classification):", True),
    (1, "Ia — Active arterial spurting — 90% rebleed risk", False),
    (1, "Ib — Active oozing — 10–27% rebleed", False),
    (1, "IIa — Non-bleeding visible vessel (NBVV) — 43–55% rebleed risk → TREAT", False),
    (1, "IIb — Adherent clot — 22% rebleed → consider endoscopic removal", False),
    (1, "IIc — Flat pigmented spot — <8% rebleed", False),
    (1, "III — Clean base — <3% rebleed", False),
    (0, "INITIAL MANAGEMENT:", True),
    (1, "Resuscitate: IV access (2 large bore), crystalloids then packed red cells; target Hb 7–9 g/dL", False),
    (1, "IV PPI (bolus + infusion) pre-endoscopy: 80 mg omeprazole → 8 mg/hr (downstages stigmata)", False),
    (1, "Urgent endoscopy within 24 h (high-risk within 12 h after resuscitation)", False),
    (1, "Endoscopic haemostasis: adrenaline injection + second modality (thermal/clips)", False),
    (1, "Post-endoscopy: IV PPI for 72 h → oral PPI; early re-feeding", False),
    (0, "REBLEED / FAILURE:", True),
    (1, "Repeat endoscopy once if rebleeds; thereafter → interventional radiology (embolisation) or surgery", False),
    (1, "Surgery: under-running of ulcer + vagotomy ± pyloroplasty (rare in current era)", False),
]
add_multi_bullet(s, bleed, 0.6, 1.55, 8.3, 5.7, font_size=12, color=DARK_TEXT)

# Right: risk scoring
add_rect(s, 9.15, 1.05, 3.8, 6.35, DARK_NAVY)
add_text(s, "Risk Stratification\nScoring Systems", 9.3, 1.08, 3.5, 0.65,
         font_size=14, bold=True, color=YELLOW_HL, align=PP_ALIGN.CENTER)

add_text(s, "BLATCHFORD SCORE (pre-endoscopy)", 9.3, 1.83, 3.5, 0.42,
         font_size=12, bold=True, color=ORANGE)
bf = [
    "Urea, Hb, SBP, HR",
    "Melaena, syncope",
    "Hepatic/cardiac disease",
    "Score 0 → safe for discharge",
    "Max score = 23",
]
add_multi_bullet(s, bf, 9.3, 2.28, 3.5, 1.5, font_size=11, color=WHITE, bullet_char="• ")

add_text(s, "ROCKALL SCORE (post-endoscopy)", 9.3, 3.88, 3.5, 0.42,
         font_size=12, bold=True, color=ORANGE)
rk = [
    "Age, shock, comorbidity",
    "Endoscopic diagnosis",
    "Stigmata of haemorrhage",
    "Score ≤2 → low risk",
    "Score ≥8 → 41% mortality",
]
add_multi_bullet(s, rk, 9.3, 4.35, 3.5, 1.5, font_size=11, color=WHITE, bullet_char="• ")

add_rect(s, 9.15, 5.95, 3.8, 1.45, RED)
add_text(s, "AIMS65 Score\nAlbumin <3 g/dL, INR >1.5,\nAMS, SBP <90, age >65\n→ predicts in-hospital mortality",
         9.25, 5.98, 3.6, 1.38, font_size=11, color=WHITE)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 14  – Complications: Perforation
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Complications — Perforation",
             "Surgical emergency · Anterior DU most common · Free air on imaging")

add_rect(s, 0.4, 1.05, 8.3, 6.3, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 6.3, ORANGE)
add_text(s, "Perforated Peptic Ulcer", 0.6, 1.08, 8.0, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
perf = [
    (0, "Second most common complication; mortality 10–40% (depends on delay to surgery & comorbidity)", False),
    (0, "ANTERIOR DU: most common perforation site → peritonitis", False),
    (0, "POSTERIOR DU: tends to bleed (GDA erosion); contained perforation → pancreatic penetration", False),
    (0, "GASTRIC perforation: less common; all require biopsy intra-op to exclude malignancy", False),
    (0, "Clinical presentation:", True),
    (1, "Sudden onset SEVERE epigastric pain — 'knife-like'; patient lies still", False),
    (1, "Rigidity → peritonitis: guarding, rebound; 'board-like' abdomen", False),
    (1, "Pain may diminish after a few hours (chemical peritonitis → bacterial → patient may feel 'better')", False),
    (1, "Referred pain to right shoulder (diaphragmatic irritation by free air)", False),
    (1, "Tachycardia, hypotension (late)", False),
    (0, "Investigations:", True),
    (1, "Erect CXR: free air under diaphragm in ~70% of cases", False),
    (1, "CT abdomen (with oral contrast): most sensitive — detects free air, fluid, ulcer location", False),
    (1, "Serum amylase: mildly elevated (ddx pancreatitis — usually >1000 U/L)", False),
    (0, "MANAGEMENT:", True),
    (1, "Resuscitation: IV fluids, NG tube, urinary catheter, IV antibiotics, PPI", False),
    (1, "Surgical repair (primary treatment): laparoscopic or open omental patch (Graham patch)", False),
    (1, "Definitive anti-ulcer procedure only if stable + no peritoneal contamination", False),
    (1, "Conservative (Tayler) management: selected patients — young, small perf, no peritonitis", False),
    (1, "Post-op: test and treat H. pylori; long-term PPI if NSAID/smoking factors remain", False),
]
add_multi_bullet(s, perf, 0.6, 1.55, 8.1, 5.7, font_size=12, color=DARK_TEXT)

# Right panel
add_rect(s, 8.95, 1.05, 4.0, 6.3, DARK_NAVY)
add_text(s, "Mortality Predictors", 9.1, 1.08, 3.75, 0.42,
         font_size=14, bold=True, color=YELLOW_HL)
mort = [
    "Delay to surgery >24 h",
    "Age >70 years",
    "ASA grade ≥3",
    "Active malignancy",
    "Haemodynamic instability",
    "Faecal peritonitis",
    "",
    "Boey Score (0–3):",
    "• Shock (SBP <100)",
    "• Perforation >24 h",
    "• Major medical illness",
    "Score 0: 0% mortality",
    "Score 3: ~100% mortality",
]
y_m = 1.57
for line in mort:
    bld = "Score" in line or "Boey" in line
    col = ORANGE if bld else WHITE
    add_text(s, line, 9.1, y_m, 3.75, 0.4,
             font_size=12, bold=bld, color=col)
    y_m += 0.38 if line else 0.2

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 15  – Complications: Gastric Outlet Obstruction
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Complications — Gastric Outlet Obstruction",
             "Pyloric stenosis · Electrolyte signature · Surgical options")

add_rect(s, 0.4, 1.05, 8.5, 6.3, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 6.3, MED_BLUE)
add_text(s, "Gastric Outlet Obstruction (GOO)", 0.6, 1.08, 8.2, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
goo = [
    (0, "Third complication of PUD; now more commonly due to gastric cancer than PUD", False),
    (0, "Mechanism: fibrotic scarring/oedema at pyloric channel or D1 from chronic/recurrent ulceration", False),
    (0, "Symptoms:", True),
    (1, "Vomiting of undigested food (hours after meal) — bile-free (obstruction pre-papilla)", False),
    (1, "Succussion splash (hand on abdomen + patient rocking)", False),
    (1, "Progressive weight loss, dehydration, satiety", False),
    (0, "Metabolic derangement — CLASSIC PATTERN:", True),
    (1, "Hypochloraemic, hypokalaemic metabolic ALKALOSIS", False),
    (1, "Mechanism: repeated vomiting → loss of H⁺ and Cl⁻ → renal compensation (HCO₃⁻ retention)", False),
    (1, "Paradoxical aciduria: kidneys excrete K⁺ (prioritise Na⁺ reabsorption) + H⁺ despite alkalosis", False),
    (1, "Labs: ↓ Na⁺, ↓ K⁺, ↓ Cl⁻, ↑ HCO₃⁻, ↑ urea (pre-renal); urine pH paradoxically acidic", False),
    (0, "INVESTIGATIONS:", True),
    (1, "Endoscopy: confirms obstruction; biopsies to exclude malignancy (essential!)", False),
    (1, "CT abdomen: gastric dilatation, site of obstruction, wall thickening", False),
    (1, "Saline load test: infuse 750 mL saline; if >400 mL remains at 30 min → obstruction", False),
    (0, "MANAGEMENT:", True),
    (1, "Step 1: NBM + NG tube decompression + IV fluid/electrolyte correction (N. saline + KCl)", False),
    (1, "Step 2: IV PPI, nutritional support", False),
    (1, "Step 3: Endoscopic balloon dilatation (for benign strictures — often requires repeat)", False),
    (1, "Step 4: Surgery if endoscopic dilation fails: truncal vagotomy + gastrojejunostomy or Billroth I/II", False),
]
add_multi_bullet(s, goo, 0.6, 1.55, 8.3, 5.7, font_size=12, color=DARK_TEXT)

add_rect(s, 9.15, 1.05, 3.8, 6.3, DARK_NAVY)
add_text(s, "Electrolyte Abnormality\nin GOO", 9.3, 1.08, 3.5, 0.65,
         font_size=14, bold=True, color=YELLOW_HL, align=PP_ALIGN.CENTER)
elec = [
    "↓ Na⁺ (mild)",
    "↓ K⁺ (hypokalaemia)",
    "↓ Cl⁻ (hypochloraemia)",
    "↑ HCO₃⁻ (alkalosis)",
    "↑ Urea (pre-renal)",
    "Urine: paradoxically ACID",
    "",
    "Treatment:",
    "0.9% NaCl + KCl IV",
    "Replace Cl⁻ and K⁺",
    "Avoid HCO₃⁻",
    "",
    "Differential for GOO:",
    "• Gastric cancer (most common now)",
    "• Chronic PUD",
    "• Pancreatic cancer",
    "• Adult hypertrophic\n  pyloric stenosis",
    "• Crohn's disease",
]
y_e = 1.85
for line in elec:
    bld = line == "Treatment:" or line == "Differential for GOO:"
    col = ORANGE if bld else (YELLOW_HL if line.startswith("↓") or line.startswith("↑") else WHITE)
    add_text(s, line, 9.3, y_e, 3.5, 0.38,
             font_size=11.5, bold=bld, color=col)
    y_e += 0.35 if line else 0.18

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 16  – Medical Management Overview
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Medical Management of PUD",
             "Acid suppression · H. pylori eradication · Mucosal protection")

# Agents table
add_rect(s, 0.4, 1.05, 12.5, 0.42, MED_BLUE)
for hdr, x in [("Drug Class", 0.45), ("Examples", 2.8), ("Mechanism", 5.5), ("Notes", 9.0)]:
    add_text(s, hdr, x, 1.07, 2.3, 0.38,
             font_size=13, bold=True, color=WHITE, v_anchor=MSO_ANCHOR.MIDDLE)

rows = [
    ("PPIs\n(1st line)", "Omeprazole 20–40 mg\nEsomeprazole, Pantoprazole\nLansoprazole, Rabeprazole",
     "Irreversible block of H⁺/K⁺-ATPase pump\non parietal cell (final common pathway)",
     "90% acid suppression; given 30 min before meals; healing: DU 4 wks, GU 8 wks"),
    ("H2-Receptor\nAntagonists", "Ranitidine (withdrawn),\nFamotidine, Cimetidine",
     "Competitive block of H2 receptors\non parietal cells",
     "Less effective than PPIs; tachyphylaxis; still useful for mild disease"),
    ("Antacids", "Al(OH)₃, Mg(OH)₂, CaCO₃",
     "Neutralise intraluminal acid",
     "Symptomatic relief only; not for healing"),
    ("Sucralfate", "Sucralfate 1 g QID",
     "Coats ulcer base; binds pepsin,\nstimulates prostaglandins",
     "Useful in ZES; avoid in renal failure (Al accumulation)"),
    ("Misoprostol", "Misoprostol 200 mcg QID",
     "PGE1 analogue — stimulates mucus,\nbicarb, mucosal blood flow",
     "GI side effects (diarrhoea); used for NSAID-GI prophylaxis; teratogenic"),
    ("Bismuth\nSalts", "Bismuth subcitrate/subsalicylate",
     "Mucosal protective coating;\nanti-H. pylori bactericidal action",
     "Component of quadruple therapy; darkens stool"),
]

for i, (cls, examp, mech, notes) in enumerate(rows):
    bg = LIGHT_BLUE if i % 2 == 0 else WHITE
    yp = 1.52 + i * 0.82
    add_rect(s, 0.4, yp, 12.5, 0.8, bg)
    add_text(s, cls, 0.45, yp+0.04, 2.3, 0.72, font_size=12, bold=True,
             color=DARK_NAVY, v_anchor=MSO_ANCHOR.MIDDLE)
    add_text(s, examp, 2.8, yp+0.04, 2.65, 0.72, font_size=11,
             color=DARK_TEXT, v_anchor=MSO_ANCHOR.MIDDLE)
    add_text(s, mech, 5.5, yp+0.04, 3.45, 0.72, font_size=11,
             color=DARK_TEXT, v_anchor=MSO_ANCHOR.MIDDLE)
    add_text(s, notes, 9.0, yp+0.04, 3.85, 0.72, font_size=10.5,
             color=DARK_TEXT, v_anchor=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 17  – H. pylori Eradication
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "H. pylori Eradication Therapy",
             "Test-and-treat · Regimens · Resistance · Confirmation of eradication")

# Regimens
add_rect(s, 0.4, 1.05, 12.5, 0.42, DARK_NAVY)
for hdr, x in [("Regimen", 0.45), ("Drugs & Duration", 3.5), ("Eradication Rate", 9.8)]:
    add_text(s, hdr, x, 1.07, 3.3, 0.38, font_size=13, bold=True, color=WHITE)

regimens = [
    ("Standard Triple Therapy\n(1st line, low clarithromycin resistance areas)",
     "PPI (standard dose BD) + Clarithromycin 500 mg BD + Amoxicillin 1 g BD — 7–14 days",
     "~80–85%"),
    ("Bismuth Quadruple\n(1st line where clarithromycin resistance >15%)",
     "PPI BD + Bismuth subcitrate QID + Metronidazole 400 mg QID + Tetracycline 500 mg QID — 10–14 days",
     "~90%"),
    ("Concomitant (Non-Bismuth\nQuadruple) Therapy",
     "PPI BD + Clarithromycin 500 mg BD + Amoxicillin 1 g BD + Metronidazole 400 mg BD — 14 days",
     "~88–90%"),
    ("Sequential Therapy",
     "Days 1–5: PPI + Amoxicillin 1 g BD; Days 6–10: PPI + Clarithromycin + Metronidazole",
     "~85–90%"),
    ("Levofloxacin-based\n(Rescue/2nd line)",
     "PPI BD + Levofloxacin 500 mg OD + Amoxicillin 1 g BD — 10–14 days",
     "~80%"),
    ("Rifabutin-based\n(3rd line / resistant cases)",
     "PPI BD + Amoxicillin 1 g BD + Rifabutin 150 mg BD — 10 days",
     "~70–80%"),
]

for i, (reg, drugs, rate) in enumerate(regimens):
    bg = LIGHT_BLUE if i % 2 == 0 else WHITE
    yp = 1.52 + i * 0.78
    add_rect(s, 0.4, yp, 12.5, 0.76, bg)
    add_text(s, reg, 0.45, yp+0.03, 3.0, 0.7, font_size=11.5, bold=False,
             color=DARK_NAVY, v_anchor=MSO_ANCHOR.MIDDLE)
    add_text(s, drugs, 3.5, yp+0.03, 6.25, 0.7, font_size=11,
             color=DARK_TEXT, v_anchor=MSO_ANCHOR.MIDDLE)
    add_text(s, rate, 9.8, yp+0.03, 2.9, 0.7, font_size=14, bold=True,
             color=GREEN, v_anchor=MSO_ANCHOR.MIDDLE, align=PP_ALIGN.CENTER)

# Bottom notes
add_rect(s, 0.4, 6.25, 12.5, 1.1, DARK_NAVY)
notes_txt = ("CONFIRM ERADICATION: UBT or SAT ≥4 weeks after completing antibiotics and ≥2 weeks after stopping PPI  |  "
             "Antibiotic resistance (especially clarithromycin, metronidazole) is the primary cause of treatment failure  |  "
             "Culture-guided therapy if 2nd-line fails  |  PPI must be continued for full healing course even after eradication (DU 4 wks, GU 8 wks)")
add_text(s, notes_txt, 0.5, 6.28, 12.3, 1.0,
         font_size=11, italic=True, color=LIGHT_BLUE,
         v_anchor=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 18  – Surgical Management
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Surgical Management",
             "Indications · Elective vs emergency · Procedures & post-operative complications")

add_rect(s, 0.4, 1.05, 7.8, 6.3, WHITE)
add_rect(s, 0.4, 1.05, 0.08, 6.3, MED_BLUE)
add_text(s, "Surgery for PUD — Current Role", 0.6, 1.08, 7.5, 0.42,
         font_size=15, bold=True, color=DARK_NAVY)
surg = [
    (0, "ELECTIVE SURGERY: now very rarely indicated (intractable disease not responding to medical Rx)", True),
    (0, "EMERGENCY SURGERY remains essential for:", True),
    (1, "Perforation — omental patch (Graham patch) ± definitive procedure", False),
    (1, "Uncontrolled haemorrhage — failed endoscopy × 2; under-running of ulcer ± vagotomy", False),
    (1, "Gastric outlet obstruction — failed endoscopic dilatation", False),
    (0, "PROCEDURES FOR DU:", True),
    (1, "Truncal vagotomy + pyloroplasty (TV+P): vagotomy to ↓ acid + drainage to avoid gastroparesis", False),
    (1, "Truncal vagotomy + antrectomy (TV+A): most effective; Billroth I or II reconstruction", False),
    (1, "Highly selective vagotomy (HSV/proximal gastric vagotomy): preserves pyloric innervation; lowest side effects; rarely used now", False),
    (0, "POST-OPERATIVE COMPLICATIONS:", True),
    (1, "Dumping syndrome (early): rapid gastric emptying → osmotic shift → vasomotor symptoms 15–30 min post-meal", False),
    (1, "Dumping syndrome (late): hyperglycaemia → insulin surge → reactive hypoglycaemia 1–3 h post-meal", False),
    (1, "Afferent loop syndrome (Billroth II): obstruction → bacterial overgrowth; bilious vomiting", False),
    (1, "Alkaline reflux gastritis: bile reflux → chronic gastritis", False),
    (1, "Post-vagotomy diarrhoea: altered intestinal motility", False),
    (1, "Stomal ulcer: recurrence at gastrojejunal anastomosis", False),
    (1, "Nutritional deficiencies: B12, iron, calcium (especially post-gastrectomy)", False),
    (1, "Gastric remnant cancer: long-term risk after Billroth II (surveillance at 15+ years)", False),
]
add_multi_bullet(s, surg, 0.6, 1.55, 7.6, 5.7, font_size=12, color=DARK_TEXT)

add_rect(s, 8.45, 1.05, 4.5, 6.3, DARK_NAVY)
add_text(s, "Surgical Procedures\n(Visual Guide)", 8.6, 1.08, 4.2, 0.65,
         font_size=14, bold=True, color=YELLOW_HL, align=PP_ALIGN.CENTER)

procs = [
    ("Graham Patch", "Omentum sutured over perforation; simple, quick"),
    ("Billroth I", "Distal gastrectomy; stomach to duodenum (gastroduodenostomy)"),
    ("Billroth II\n(Pólya)", "Distal gastrectomy; stomach to jejunum (loop gastrojejunostomy); duodenal stump closed"),
    ("Roux-en-Y", "Gastrojejunostomy with Roux limb; minimises alkaline reflux"),
    ("HSV", "Denervates parietal cell mass; preserves pylorus; elective only"),
]
y_p = 1.82
for pname, pdesc in procs:
    add_rect(s, 8.45, y_p, 4.5, 0.98, MED_BLUE)
    add_text(s, pname, 8.58, y_p+0.04, 4.2, 0.42, font_size=13, bold=True,
             color=YELLOW_HL, v_anchor=MSO_ANCHOR.MIDDLE)
    add_text(s, pdesc, 8.58, y_p+0.44, 4.2, 0.5, font_size=11, color=WHITE,
             v_anchor=MSO_ANCHOR.MIDDLE)
    y_p += 1.05

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 19  – Special Situations & Follow-up
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, LIGHT_GRAY)
slide_header(s, "Special Situations, Follow-up & Cancer Risk",
             "Refractory ulcers · Pregnancy · Elderly · Surveillance")

boxes2 = [
    ("Refractory Ulcers",
     ["Failure to heal after 8–12 weeks of PPI", "Check compliance; confirm H. pylori eradication (UBT/SAT)",
      "Rule out NSAID/aspirin use; smoking", "Serum gastrin → ZES?; consider IgG4 disease",
      "Biopsy: exclude malignancy; resistance testing (culture)", "Extend/intensify PPI; switch to bismuth quadruple therapy",
      "Rarely: surgery for truly intractable disease"], MED_BLUE),
    ("Elderly Patients",
     ["Higher risk of complications (bleeding, perforation) with fewer symptoms",
      "'Silent ulcer' common — first presentation may be haemorrhage", "NSAIDs + anticoagulants = very high risk",
      "Long-term PPI maintenance often required", "Close monitoring; early endoscopy for any symptom change"], DARK_NAVY),
    ("Pregnancy & PUD",
     ["H. pylori eradication deferred until after delivery", "PPIs: omeprazole/pantoprazole — generally considered safe",
      "Avoid misoprostol (teratogenic/abortifacient)", "Endoscopy: safe after first trimester if absolutely indicated",
      "Manage conservatively where possible"], GREEN),
    ("Follow-up & Cancer Surveillance",
     ["ALL gastric ulcers: repeat OGD at 6–8 weeks to confirm healing and re-biopsy",
      "Failure to heal → early endoscopic follow-up → exclude malignancy", "H. pylori eradication: ↓ gastric cancer risk (strongest modifiable risk factor)",
      "Post-gastrectomy: endoscopic surveillance starting 15 years post-op (Billroth II especially)",
      "MALT lymphoma: follow-up after H. pylori eradication for regression"], ORANGE),
]

pos2 = [(0.4, 1.05), (6.8, 1.05), (0.4, 4.3), (6.8, 4.3)]
for (bx, by), (title, items, col) in zip(pos2, boxes2):
    add_rect(s, bx, by, 6.0, 0.42, col)
    add_text(s, title, bx+0.1, by+0.03, 5.8, 0.36,
             font_size=14, bold=True, color=WHITE, v_anchor=MSO_ANCHOR.MIDDLE)
    add_rect(s, bx, by+0.42, 6.0, 2.82, WHITE)
    add_multi_bullet(s, items, bx+0.15, by+0.48, 5.75, 2.72, font_size=12, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════════════════════════
# SLIDE 20  – Summary / Key Take-Home Messages
# ═══════════════════════════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank_layout)
add_rect(s, 0, 0, 13.333, 7.5, DARK_NAVY)
add_rect(s, 0, 0, 13.333, 1.05, MED_BLUE)
add_text(s, "Key Take-Home Messages", 0.3, 0.08, 12.8, 0.9,
         font_size=30, bold=True, color=WHITE, v_anchor=MSO_ANCHOR.MIDDLE)

msgs = [
    ("1", "H. pylori and NSAIDs cause >90% of PUD. Always determine the aetiology — it drives management."),
    ("2", "No acid, no ulcer — but eradicating H. pylori transforms PUD from a chronic relapsing to a curable disease."),
    ("3", "ALL gastric ulcers must be biopsied and endoscopically confirmed healed at 6–8 weeks — malignancy must be excluded."),
    ("4", "Forrest IIa (visible vessel) carries ~50% rebleed risk — mandates endoscopic haemostasis; Forrest III (clean base) is safe for early discharge."),
    ("5", "GOO produces the classic hypochloraemic, hypokalaemic metabolic alkalosis — restore Cl⁻ and K⁺ before surgery."),
    ("6", "Eradication confirmation (UBT/SAT) must be performed ≥4 weeks post-antibiotics and ≥2 weeks off PPI."),
    ("7", "Perforated DU: anterior → peritonitis; posterior → bleeds GDA. Boey score predicts surgical mortality."),
    ("8", "Surgery is now almost exclusively for emergency complications — the era of elective acid-reducing surgery is over."),
]

for i, (num, msg) in enumerate(msgs):
    yp = 1.15 + i * 0.76
    add_rect(s, 0.4, yp, 0.55, 0.62, ORANGE)
    add_text(s, num, 0.4, yp+0.03, 0.55, 0.56, font_size=22, bold=True,
             color=WHITE, align=PP_ALIGN.CENTER, v_anchor=MSO_ANCHOR.MIDDLE)
    add_rect(s, 0.98, yp, 11.95, 0.62, RGBColor(0x14, 0x38, 0x5A))
    add_text(s, msg, 1.1, yp+0.03, 11.7, 0.56, font_size=14, color=WHITE,
             v_anchor=MSO_ANCHOR.MIDDLE)

add_text(s, "Sources: Schwartz's Principles of Surgery 11e · Sleisenger & Fordtran's GI & Liver Disease 11e\n"
            "Bailey & Love's Short Practice of Surgery 28e · Robbins & Kumar Basic Pathology · Yamada's Textbook of Gastroenterology 7e",
         0.4, 7.1, 12.5, 0.35, font_size=10, italic=True, color=LIGHT_BLUE,
         align=PP_ALIGN.CENTER)

# ─────────────────────────────────────────────────────────────────
out_path = "/tmp/workspace/pud-presentation/Peptic_Ulcer_Disease_PG.pptx"
prs.save(out_path)
print(f"Saved: {out_path}")
print(f"Slides: {len(prs.slides)}")

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

# ─── LIGHT THEME PALETTE ───────────────────────────────────────────
WHITE       = RGBColor(0xFF, 0xFF, 0xFF)
OFF_WHITE   = RGBColor(0xF7, 0xF9, 0xFC)
LIGHT_GRAY  = RGBColor(0xEE, 0xF2, 0xF7)
MID_GRAY    = RGBColor(0xD0, 0xD8, 0xE4)
DARK_TEXT   = RGBColor(0x1A, 0x1A, 0x2E)
MED_TEXT    = RGBColor(0x3D, 0x3D, 0x5C)

# Accent colours (vivid but clean on white)
DEEP_TEAL   = RGBColor(0x0B, 0x6E, 0x7C)   # headers / section titles
TEAL_LIGHT  = RGBColor(0xD6, 0xF0, 0xF3)   # content backgrounds
MED_TEAL    = RGBColor(0x1A, 0x9A, 0xAB)   # subheaders
CRIMSON     = RGBColor(0xC0, 0x30, 0x30)   # danger / alerts
CRIMSON_LIGHT = RGBColor(0xFD, 0xEC, 0xEC)
AMBER       = RGBColor(0xD9, 0x7B, 0x0A)   # caution
AMBER_LIGHT = RGBColor(0xFE, 0xF3, 0xD7)
PURPLE      = RGBColor(0x5E, 0x35, 0x9E)   # pharmacology
PURPLE_LIGHT= RGBColor(0xEF, 0xE8, 0xFB)
GREEN       = RGBColor(0x1A, 0x7C, 0x45)
GREEN_LIGHT = RGBColor(0xE4, 0xF7, 0xEC)
BLUE        = RGBColor(0x1A, 0x56, 0xAB)
BLUE_LIGHT  = RGBColor(0xE4, 0xEE, 0xFB)

prs = Presentation()
prs.slide_width  = Inches(13.333)
prs.slide_height = Inches(7.5)
blank = prs.slide_layouts[6]

# ─── UTILITIES ─────────────────────────────────────────────────────
def rect(slide, x, y, w, h, fill, line=False):
    sh = slide.shapes.add_shape(1, Inches(x), Inches(y), Inches(w), Inches(h))
    sh.fill.solid(); sh.fill.fore_color.rgb = fill
    if line:
        sh.line.color.rgb = MID_GRAY; sh.line.width = Pt(0.5)
    else:
        sh.line.fill.background()
    return sh

def txt(slide, text, x, y, w, h,
        sz=14, bold=False, italic=False, color=DARK_TEXT,
        align=PP_ALIGN.LEFT, va=MSO_ANCHOR.TOP, wrap=True, name="Calibri"):
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame; tf.word_wrap = wrap; tf.vertical_anchor = va
    tf.margin_left = tf.margin_right = Inches(0.04)
    tf.margin_top  = tf.margin_bottom = Inches(0.02)
    p = tf.paragraphs[0]; p.alignment = align
    r = p.add_run(); r.text = text
    r.font.name = name; r.font.size = Pt(sz)
    r.font.bold = bold; r.font.italic = italic; r.font.color.rgb = color
    return tb

def bullets(slide, items, x, y, w, h, sz=13, color=DARK_TEXT, bullet="▸ "):
    """items: list of str, or (level, text, bold) tuples"""
    tb = slide.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h))
    tf = tb.text_frame; tf.word_wrap = True; tf.vertical_anchor = MSO_ANCHOR.TOP
    tf.margin_left = Inches(0.08); tf.margin_right = Inches(0.05)
    tf.margin_top  = Inches(0.04); tf.margin_bottom = Inches(0.04)
    first = True
    for item in items:
        lvl, text, bold = (item if not isinstance(item, str) else (0, item, False))
        p = tf.paragraphs[0] if first else tf.add_paragraph()
        first = False
        p.space_before = Pt(1); p.space_after = Pt(1)
        r = p.add_run()
        r.text = "    " * lvl + bullet + text
        r.font.name = "Calibri"; r.font.size = Pt(sz)
        r.font.bold = bold; r.font.color.rgb = color
    return tb

def header_bar(slide, title, subtitle=None, accent=DEEP_TEAL):
    """Crisp top bar on white slide"""
    bh = 1.0
    rect(slide, 0, 0, 13.333, bh, accent)
    txt(slide, title, 0.28, 0.08, 12.5, 0.6,
        sz=30, bold=True, color=WHITE, va=MSO_ANCHOR.MIDDLE)
    if subtitle:
        txt(slide, subtitle, 0.28, 0.65, 12.5, 0.32,
            sz=13, italic=True, color=RGBColor(0xCC, 0xEE, 0xF2))
    # thin accent line below bar
    rect(slide, 0, bh, 13.333, 0.06, MED_TEAL)

def section_card(slide, title, x, y, w, h, accent=DEEP_TEAL, bg=TEAL_LIGHT):
    rect(slide, x, y, w, 0.38, accent)
    txt(slide, title, x+0.1, y+0.03, w-0.2, 0.32,
        sz=13, bold=True, color=WHITE, va=MSO_ANCHOR.MIDDLE)
    rect(slide, x, y+0.38, w, h-0.38, bg, line=True)

def kpi_box(slide, number, label, x, y, w, h, accent=DEEP_TEAL, bg=TEAL_LIGHT):
    rect(slide, x, y, w, h, bg, line=True)
    rect(slide, x, y, w, 0.06, accent)
    txt(slide, number, x, y+0.1, w, h*0.52,
        sz=30, bold=True, color=accent, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE)
    txt(slide, label, x, y+h*0.55, w, h*0.42,
        sz=11, color=MED_TEXT, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════
# SLIDE 1 — Title
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
rect(s, 0, 0, 13.333, 3.6, DEEP_TEAL)
# diagonal accent
rect(s, 0, 3.52, 13.333, 0.16, MED_TEAL)
rect(s, 0, 3.68, 13.333, 0.06, AMBER)

txt(s, "IMMUNE THROMBOCYTOPENIA", 0.8, 0.7, 11.8, 1.5,
    sz=46, bold=True, color=WHITE, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE)
txt(s, "(ITP)", 0.8, 2.0, 11.8, 0.65,
    sz=28, bold=True, color=RGBColor(0xA0, 0xE0, 0xE8), align=PP_ALIGN.CENTER)
txt(s, "A Comprehensive Postgraduate Review  |  Department of Internal Medicine",
    0.8, 2.75, 11.8, 0.55, sz=16, italic=True,
    color=RGBColor(0xCC, 0xEE, 0xF2), align=PP_ALIGN.CENTER)

txt(s, "Formerly: Idiopathic Thrombocytopenic Purpura", 1.5, 3.95, 10.3, 0.55,
    sz=17, italic=True, color=MED_TEXT, align=PP_ALIGN.CENTER)
txt(s, "Sources: Harrison's Principles of Internal Medicine 22e (2025) · Goldman-Cecil Medicine · Washington Manual of Medical Therapeutics\n"
       "Rosen's Emergency Medicine · Sabiston Textbook of Surgery · Fischer's Mastery of Surgery",
    0.8, 6.85, 11.8, 0.55, sz=10.5, italic=True,
    color=MED_TEXT, align=PP_ALIGN.CENTER)

# ═══════════════════════════════════════════════════════════
# SLIDE 2 — Outline
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "Lecture Outline", "What we will cover today")

topics_L = [
    "1.  Definition & Terminology",
    "2.  Epidemiology",
    "3.  Classification (Primary vs Secondary)",
    "4.  Pathophysiology",
    "5.  Clinical Presentation",
    "6.  Approach to Diagnosis",
    "7.  Differential Diagnosis",
    "8.  Investigations",
]
topics_R = [
    "9.  ASH 2019 Guidelines — Disease Phases",
    "10. Treatment — First-line",
    "11. Treatment — Second-line (Rituximab / TPO-RA)",
    "12. Treatment — Splenectomy",
    "13. Emergency Management (Severe/Life-threatening)",
    "14. ITP in Special Populations",
    "15. Monitoring & Follow-up",
    "16. Key Take-Home Messages",
]
rect(s, 0.5, 1.15, 5.9, len(topics_L)*0.5+0.2, TEAL_LIGHT, line=True)
rect(s, 0.5, 1.15, 0.06, len(topics_L)*0.5+0.2, DEEP_TEAL)
for i, t in enumerate(topics_L):
    txt(s, t, 0.65, 1.22+i*0.5, 5.65, 0.47, sz=14.5, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)

rect(s, 6.95, 1.15, 5.9, len(topics_R)*0.5+0.2, TEAL_LIGHT, line=True)
rect(s, 6.95, 1.15, 0.06, len(topics_R)*0.5+0.2, MED_TEAL)
for i, t in enumerate(topics_R):
    txt(s, t, 7.1, 1.22+i*0.5, 5.65, 0.47, sz=14.5, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════
# SLIDE 3 — Definition & Terminology
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Definition & Terminology")

rect(s, 0.45, 1.12, 12.4, 1.8, TEAL_LIGHT, line=True)
rect(s, 0.45, 1.12, 0.07, 1.8, DEEP_TEAL)
txt(s, "Definition", 0.62, 1.14, 11.8, 0.42, sz=14, bold=True, color=DEEP_TEAL)
txt(s, "Immune Thrombocytopenia (ITP) is an acquired autoimmune disorder characterised by isolated thrombocytopenia "
       "(platelet count <100 × 10⁹/L) in the absence of an identifiable underlying cause. It results from immune-mediated "
       "platelet destruction AND inhibition of platelet release from megakaryocytes — making it a disorder of both "
       "decreased platelet survival and impaired production.",
    0.62, 1.58, 11.8, 1.28, sz=14.5, color=DARK_TEXT, wrap=True)

rect(s, 0.45, 3.05, 5.9, 4.3, OFF_WHITE, line=True)
rect(s, 0.45, 3.05, 0.07, 4.3, AMBER)
txt(s, "Terminology Evolution", 0.62, 3.08, 5.6, 0.4, sz=13, bold=True, color=AMBER)
term_items = [
    "\"Idiopathic\" → \"Immune\" (cause now understood)",
    "\"Purpura\" removed from name (not always present)",
    "Current preferred term: Immune Thrombocytopenia (ITP)",
    "ASH 2019 & IWG (International Working Group) consensus terminology",
    "Threshold changed: platelet <100 × 10⁹/L (previously <150 × 10⁹/L)",
    "Rationale: counts 100–150 × 10⁹/L usually benign; ~10% develop true ITP over 10 years",
]
bullets(s, term_items, 0.62, 3.52, 5.68, 3.7, sz=13)

rect(s, 6.65, 3.05, 6.2, 4.3, OFF_WHITE, line=True)
rect(s, 6.65, 3.05, 0.07, 4.3, MED_TEAL)
txt(s, "ITP Disease Phases (IWG 2010 / ASH 2019)", 6.82, 3.08, 5.9, 0.4, sz=13, bold=True, color=MED_TEAL)

phases = [
    ("Newly Diagnosed", "0–3 months from diagnosis", TEAL_LIGHT, DEEP_TEAL),
    ("Persistent", "3–12 months; failed to achieve CR or SR spontaneously or after stopping treatment", AMBER_LIGHT, AMBER),
    ("Chronic", ">12 months duration; not in spontaneous or treatment-maintained remission", CRIMSON_LIGHT, CRIMSON),
    ("Severe ITP", "Platelet <20 × 10⁹/L with bleeding requiring treatment", PURPLE_LIGHT, PURPLE),
    ("Refractory", "Failure to respond or relapsed after splenectomy", BLUE_LIGHT, BLUE),
]
yp = 3.55
for name, desc, bg, accent in phases:
    rect(s, 6.65, yp, 6.2, 0.72, bg, line=True)
    rect(s, 6.65, yp, 0.07, 0.72, accent)
    txt(s, name, 6.82, yp+0.04, 2.4, 0.64, sz=12.5, bold=True, color=accent, va=MSO_ANCHOR.MIDDLE)
    txt(s, desc, 9.3, yp+0.04, 3.4, 0.64, sz=11.5, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)
    yp += 0.76

# ═══════════════════════════════════════════════════════════
# SLIDE 4 — Epidemiology
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "Epidemiology")

# KPI boxes
kpi_data = [
    ("5–10", "per 100,000\nadults/year\n(incidence)"),
    ("9.5", "per 100,000\n(children/year)"),
    ("3:1", "Female:Male\nratio (adults)"),
    ("~80%", "Children: spontaneous\nremission rate"),
    ("30–40%", "Adults who relapse\nafter 1st-line therapy"),
    ("~60%", "Long-term remission\nafter splenectomy"),
]
kpi_accs = [DEEP_TEAL, MED_TEAL, BLUE, GREEN, AMBER, PURPLE]
kpi_bgs  = [TEAL_LIGHT, TEAL_LIGHT, BLUE_LIGHT, GREEN_LIGHT, AMBER_LIGHT, PURPLE_LIGHT]
for i, ((num, lbl), acc, bg) in enumerate(zip(kpi_data, kpi_accs, kpi_bgs)):
    col, row = i % 3, i // 3
    kpi_box(s, num, lbl, 0.5 + col*4.27, 1.15 + row*1.85, 3.9, 1.65, acc, bg)

# Bottom section
rect(s, 0.5, 4.95, 12.4, 2.4, WHITE, line=True)
rect(s, 0.5, 4.95, 0.07, 2.4, DEEP_TEAL)
txt(s, "Key Epidemiological Facts", 0.67, 4.98, 11.7, 0.4, sz=13, bold=True, color=DEEP_TEAL)
epi_facts = [
    (0, "BIMODAL age distribution: children 1–5 years old (acute, post-viral) AND adults >60 years (chronic, insidious)", False),
    (0, "Children: male = female; mainly acute post-infectious; >90% self-limited remission within weeks", False),
    (0, "Adults: female predominance (F:M = 3:1); chronic course; rare spontaneous remission", False),
    (0, "Geographic variation in H. pylori association — relevant in regions with high H. pylori prevalence", False),
    (0, "Secondary ITP accounts for ~20% of all cases; SLE and HIV are most common underlying conditions", False),
]
bullets(s, epi_facts, 0.67, 5.42, 12.1, 1.85, sz=13)

# ═══════════════════════════════════════════════════════════
# SLIDE 5 — Classification
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Classification — Primary vs Secondary ITP",
           "Diagnosis of exclusion — secondary causes must be actively excluded")

# Primary
section_card(s, "PRIMARY ITP", 0.45, 1.12, 6.0, 2.85, DEEP_TEAL, TEAL_LIGHT)
primary = [
    "No identifiable underlying cause or precipitant",
    "Diagnosis of exclusion — secondary causes ruled out",
    "Accounts for ~80% of all ITP cases",
    "Pathophysiology: autoantibodies (mainly IgG anti-GPIIb/IIIa) → platelet opsonisation → splenic destruction",
    "Also: T-cell mediated cytotoxicity; impaired megakaryopoiesis",
]
bullets(s, primary, 0.55, 1.55, 5.8, 2.3, sz=12.5)

# Secondary
section_card(s, "SECONDARY ITP", 6.8, 1.12, 6.1, 2.85, CRIMSON, CRIMSON_LIGHT)
secondary = [
    "Accounts for ~20% of ITP cases",
    "Treatment must address underlying cause first",
]
bullets(s, secondary, 6.9, 1.55, 5.9, 0.75, sz=12.5, color=DARK_TEXT)

sec_causes = [
    ("Autoimmune", "SLE, RA, antiphospholipid syndrome, Evans' syndrome", TEAL_LIGHT, DEEP_TEAL),
    ("Infections", "HIV, HCV, HBV, EBV (infectious mono), H. pylori, CMV, varicella, rubella", AMBER_LIGHT, AMBER),
    ("Haematological", "CLL, NHL, Hodgkin lymphoma, myelodysplastic syndromes", PURPLE_LIGHT, PURPLE),
    ("Drugs", "Heparin (HIT), quinidine, quinine, sulfonamides, vancomycin, β-lactams, GPIIb/IIIa inhibitors", CRIMSON_LIGHT, CRIMSON),
    ("Other", "Post-vaccine (rare), post-transfusion purpura, pregnancy-related", BLUE_LIGHT, BLUE),
]
yp = 2.36
for name, desc, bg, accent in sec_causes:
    rect(s, 6.8, yp, 6.1, 0.55, bg, line=True)
    rect(s, 6.8, yp, 0.06, 0.55, accent)
    txt(s, name, 6.9, yp+0.04, 1.7, 0.47, sz=11.5, bold=True, color=accent, va=MSO_ANCHOR.MIDDLE)
    txt(s, desc, 8.65, yp+0.04, 4.1, 0.47, sz=11, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)
    yp += 0.58

# Bottom: Drug-induced note
rect(s, 0.45, 4.05, 12.45, 1.5, AMBER_LIGHT, line=True)
rect(s, 0.45, 4.05, 0.07, 1.5, AMBER)
txt(s, "Drug-Induced ITP (DITP) — Important Distinction", 0.62, 4.08, 12.0, 0.4,
    sz=13, bold=True, color=AMBER)
txt(s, "DITP is caused by drug-dependent platelet antibodies — distinct from direct bone marrow suppression. "
       "Diagnosis: thrombocytopenia improves with drug cessation, recurs on rechallenge. "
       "Common agents: heparin (HIT — see separate pathway), quinine/quinidine (strongest evidence), "
       "sulfonamides, vancomycin, procainamide, gold salts, GPIIb/IIIa inhibitors.",
    0.62, 4.52, 12.1, 0.95, sz=13, color=DARK_TEXT)

# Pseudothrombocytopenia note
rect(s, 0.45, 5.65, 12.45, 1.7, LIGHT_GRAY, line=True)
rect(s, 0.45, 5.65, 0.07, 1.7, MID_GRAY)
txt(s, "⚠ Pseudothrombocytopenia — ALWAYS EXCLUDE FIRST", 0.62, 5.68, 12.0, 0.42,
    sz=13, bold=True, color=DARK_TEXT)
pseudo = [
    "EDTA-dependent platelet agglutination — most common cause of artefactual low platelet count",
    "Check: peripheral blood smear (platelet clumps); repeat count in citrate or heparin tube",
    "Giant platelets (e.g. MYH9 mutations, Bernard-Soulier) miscounted as WBCs by automated analysers",
]
bullets(s, pseudo, 0.62, 6.14, 12.1, 1.12, sz=12.5)

# ═══════════════════════════════════════════════════════════
# SLIDE 6 — Pathophysiology
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "Pathophysiology",
           "Dual mechanism: increased platelet destruction + impaired platelet production")

# Left: Destruction pathway
section_card(s, "PLATELET DESTRUCTION (Primary Mechanism)", 0.45, 1.12, 7.8, 4.3, DEEP_TEAL, TEAL_LIGHT)
destroy = [
    (0, "B CELLS produce autoantibodies — primarily IgG, directed against platelet surface glycoproteins:", True),
    (1, "GPIIb/IIIa (integrin αIIbβ3) — MOST COMMON target (~60–70%)", False),
    (1, "GPIb/IX (von Willebrand factor receptor) — second most common", False),
    (1, "Other targets: GPIa/IIa, GPIV, GPVI", False),
    (0, "Antibody-coated platelets → opsonised → FcγR-mediated phagocytosis by:", True),
    (1, "Splenic macrophages (main site) — splenectomy effective in ~80%", False),
    (1, "Hepatic Kupffer cells (secondary site) — post-splenectomy destruction here", False),
    (0, "T CELL-MEDIATED CYTOTOXICITY: CD8+ cytotoxic T cells directly kill antibody-coated platelets", False),
    (0, "T REGULATORY CELL (Treg) DEFICIENCY: loss of peripheral immune tolerance — allows autoreactive B/T cells to proliferate", False),
    (0, "COMPLEMENT activation (IgG + IgM): contributes to platelet clearance in some patients", False),
    (0, "H. pylori: molecular mimicry? Cag A protein cross-reacts with GPIIb/IIIa in some patients", False),
]
bullets(s, destroy, 0.55, 1.55, 7.65, 3.75, sz=12.5)

# Right: Impaired production
section_card(s, "IMPAIRED PLATELET PRODUCTION", 8.55, 1.12, 4.35, 4.3, AMBER, AMBER_LIGHT)
produce = [
    (0, "MEGAKARYOCYTE SUPPRESSION:", True),
    (1, "Anti-GPIIb/IIIa antibodies cross-react with megakaryocyte surface GPIIb/IIIa", False),
    (1, "→ Inhibits platelet release and proplatelet formation", False),
    (1, "→ Megakaryocyte apoptosis", False),
    (0, "THROMBOPOIETIN (TPO) paradox:", True),
    (1, "TPO levels are NOT elevated in ITP (unlike in aplastic anaemia)", False),
    (1, "Because platelets + megakaryocytes normally clear TPO", False),
    (1, "With fewer megakaryocytes, less TPO feedback", False),
    (0, "BONE MARROW findings:", True),
    (1, "Normal or increased megakaryocytes", False),
    (1, "Young/immature megakaryocytes (impaired maturation)", False),
    (1, "Normal RBC + WBC precursors (helps exclude aplasia/MDS)", False),
]
bullets(s, produce, 8.65, 1.55, 4.2, 3.75, sz=11.5)

# Bottom: therapeutic implications
rect(s, 0.45, 5.5, 12.45, 1.85, PURPLE_LIGHT, line=True)
rect(s, 0.45, 5.5, 0.07, 1.85, PURPLE)
txt(s, "Therapeutic Implications of Dual Mechanism", 0.62, 5.53, 12.0, 0.42, sz=13, bold=True, color=PURPLE)
impl = [
    (0, "Corticosteroids: ↓ FcγR expression on macrophages + ↓ antibody production + ↑ platelet production", False),
    (0, "IVIG / anti-D: saturate FcγRs → block reticuloendothelial destruction → rapid platelet rise", False),
    (0, "Rituximab (anti-CD20): depletes B cells → ↓ autoantibody production", False),
    (0, "TPO-receptor agonists (eltrombopag, romiplostim, avatrombopag): stimulate megakaryopoiesis → ↑ platelet production", False),
    (0, "Splenectomy: removes primary site of destruction AND primary B-cell autoantibody production", False),
]
bullets(s, impl, 0.62, 5.99, 12.1, 1.28, sz=12.5, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════
# SLIDE 7 — Clinical Presentation
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Clinical Presentation",
           "Predominantly mucocutaneous bleeding · May be asymptomatic (incidental finding)")

# Left: Main presentation
section_card(s, "SYMPTOMS & SIGNS", 0.45, 1.12, 7.8, 3.5, DEEP_TEAL, TEAL_LIGHT)
pres = [
    (0, "SKIN FINDINGS (most visible):", True),
    (1, "Petechiae — non-blanching, pinpoint (<2 mm); gravity-dependent (ankles, shins)", False),
    (1, "Purpura — non-blanching confluent lesions (2–10 mm)", False),
    (1, "Ecchymoses — easy bruising disproportionate to trauma", False),
    (0, "MUCOSAL BLEEDING:", True),
    (1, "Oral (gingival, mucosal): 'wet purpura' — haemorrhagic bullae in mouth → HIGH-RISK sign", False),
    (1, "Epistaxis — may be prolonged and difficult to control", False),
    (1, "Menorrhagia — heavy menstrual bleeding (major concern in reproductive-age women)", False),
    (1, "GI bleeding — melaena, haematochezia (less common)", False),
    (0, "SERIOUS / LIFE-THREATENING (rare):", True),
    (1, "Intracranial haemorrhage (ICH) — <1% but most feared; risk ↑ with platelet <10 × 10⁹/L", False),
    (1, "Retinal haemorrhage — heralds imminent severe bleeding; requires urgent treatment", False),
    (1, "Haematuria", False),
    (0, "ASYMPTOMATIC: many patients — incidental thrombocytopenia on routine CBC", False),
    (0, "PHYSICAL EXAMINATION: usually NO splenomegaly, NO lymphadenopathy, NO hepatomegaly", False),
    (0, "  → Presence of organomegaly / lymphadenopathy suggests SECONDARY cause — investigate further", False),
]
bullets(s, pres, 0.55, 1.55, 7.65, 3.0, sz=12.5)

# Right: Children vs Adults comparison
section_card(s, "CHILDREN vs ADULTS", 8.55, 1.12, 4.35, 3.5, BLUE, BLUE_LIGHT)
comp = [
    ("Feature", "Children", "Adults"),
    ("Onset", "Acute, abrupt", "Insidious, gradual"),
    ("Preceding viral", "Common (<3 wk)", "Uncommon"),
    ("Platelet nadir", "Often <20", "Variable"),
    ("Spont. remission", ">80–90%", "Rare (<10%)"),
    ("Course", "Self-limited weeks", "Chronic (>12 mo)"),
    ("Sex", "M = F", "F > M (3:1)"),
    ("Peak age", "2–6 years", ">60 years"),
    ("ICH risk", "<0.5%", "~1%"),
]
rect(s, 8.55, 1.5, 4.35, 0.38, BLUE)
for j, hdr in enumerate(comp[0]):
    xo = [8.55, 9.8, 11.2][j]; wo = [1.2, 1.35, 1.25][j]
    txt(s, hdr, xo+0.05, 1.52, wo, 0.34, sz=11, bold=True, color=WHITE, va=MSO_ANCHOR.MIDDLE)
for i, row in enumerate(comp[1:]):
    yp = 1.9 + i*0.33
    bg = BLUE_LIGHT if i%2==0 else WHITE
    rect(s, 8.55, yp, 4.35, 0.33, bg)
    for j, cell in enumerate(row):
        xo = [8.55, 9.8, 11.2][j]; wo = [1.2, 1.35, 1.25][j]
        bld = j == 0
        txt(s, cell, xo+0.05, yp+0.02, wo, 0.29, sz=11, bold=bld, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)

# Bottom warning box
rect(s, 0.45, 4.72, 12.45, 2.63, CRIMSON_LIGHT, line=True)
rect(s, 0.45, 4.72, 0.07, 2.63, CRIMSON)
txt(s, "⚠  Warning Signs Requiring URGENT Evaluation & Admission", 0.62, 4.75, 12.0, 0.42,
    sz=13, bold=True, color=CRIMSON)
warn = [
    (0, "Wet purpura (haemorrhagic oral bullae) — implies platelet count usually <10–20 × 10⁹/L", False),
    (0, "Retinal haemorrhages on fundoscopy → immediate treatment required", False),
    (0, "Headache, confusion, focal neurology → suspect intracranial haemorrhage → urgent CT head", False),
    (0, "Haemodynamic instability / haemorrhagic shock from GI or genitourinary bleeding", False),
    (0, "Platelet count <10 × 10⁹/L regardless of symptoms → consider hospitalisation", False),
]
bullets(s, warn, 0.62, 5.22, 12.1, 2.0, sz=12.5, color=CRIMSON, bullet="▶ ")

# ═══════════════════════════════════════════════════════════
# SLIDE 8 — CLINICAL IMAGE SLIDE
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "Clinical & Pathological Features — Visual Gallery", "Educational imaging")

# image placeholders (will embed after script runs)
rect(s, 0.4, 1.15, 5.8, 4.2, LIGHT_GRAY, line=True)
txt(s, "[Image 1: Petechiae & Purpura in ITP]", 0.4, 1.15, 5.8, 4.2,
    sz=13, color=MED_TEXT, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE, italic=True)

rect(s, 6.55, 1.15, 6.3, 4.2, LIGHT_GRAY, line=True)
txt(s, "[Image 2: Drug-induced ITP — wet purpura, ecchymoses, petechiae composite]", 6.55, 1.15, 6.3, 4.2,
    sz=13, color=MED_TEXT, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE, italic=True)

rect(s, 0.4, 5.48, 5.8, 1.9, TEAL_LIGHT, line=True)
txt(s, "Non-blanching petechiae on lower limbs\n(characteristic of thrombocytopenic purpura, platelet count typically <20 × 10⁹/L)",
    0.45, 5.52, 5.68, 1.82, sz=12, italic=True, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)

rect(s, 6.55, 5.48, 6.3, 1.9, TEAL_LIGHT, line=True)
txt(s, "Multisite bleeding: petechiae (lower limbs), ecchymosis (axilla), wet purpura (oral mucosa)\n"
       "Wet purpura = haemorrhagic bullae in mouth — HIGH-RISK marker demanding urgent treatment",
    6.6, 5.52, 6.18, 1.82, sz=12, italic=True, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════
# SLIDE 9 — Diagnostic Approach
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Diagnostic Approach",
           "ITP is a DIAGNOSIS OF EXCLUSION — no single confirmatory test")

# Flow
steps = [
    ("Step 1", "Confirm Thrombocytopenia", "Repeat CBC; peripheral blood smear (clumps, morphology)", DEEP_TEAL, TEAL_LIGHT),
    ("Step 2", "Exclude Pseudothrombocytopenia", "Smear for platelet clumps; repeat in citrate tube", MED_TEAL, TEAL_LIGHT),
    ("Step 3", "Detailed History & Examination", "Drug history · Viral symptoms · Autoimmune symptoms · Lymphadenopathy / organomegaly", BLUE, BLUE_LIGHT),
    ("Step 4", "Mandatory Lab Tests", "FBC + differential · Blood film · HIV · HCV · HBV · Peripheral smear", AMBER, AMBER_LIGHT),
    ("Step 5", "Secondary Cause Workup", "ANA / anti-dsDNA (SLE) · APLA · Blood group (Rh) · Immunoglobulins · SPEP · H. pylori (endemic areas)", PURPLE, PURPLE_LIGHT),
    ("Step 6", "Targeted Tests if Indicated", "DAT/Coombs (Evans' syndrome) · Reticulocyte count · LDH / haptoglobin (haemolysis) · Coagulation screen · Fasting glucose (steroid baseline)", GREEN, GREEN_LIGHT),
    ("Step 7", "Bone Marrow Examination (if needed)", "NOT routine; reserve for: atypical features, age >60, failure to respond, suspicion of MDS/leukaemia, splenectomy planning", CRIMSON, CRIMSON_LIGHT),
]
for i, (step, title, desc, accent, bg) in enumerate(steps):
    yp = 1.13 + i * 0.86
    rect(s, 0.45, yp, 1.5, 0.78, accent)
    txt(s, step, 0.48, yp+0.03, 1.44, 0.72, sz=13, bold=True,
        color=WHITE, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE)
    rect(s, 1.97, yp, 10.9, 0.78, bg, line=True)
    txt(s, title, 2.07, yp+0.04, 3.8, 0.36, sz=13, bold=True, color=accent)
    txt(s, desc, 2.07, yp+0.40, 10.7, 0.34, sz=12, color=DARK_TEXT)

    # Arrow (except last)
    if i < len(steps) - 1:
        rect(s, 0.9, yp + 0.78, 0.6, 0.08, accent)

# ═══════════════════════════════════════════════════════════
# SLIDE 10 — Differential Diagnosis
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "Differential Diagnosis of Thrombocytopenia",
           "Categorised by mechanism — critical to distinguish from ITP")

diffs = [
    ("Increased Platelet Destruction — IMMUNE", DEEP_TEAL, TEAL_LIGHT, [
        "Primary ITP",
        "Secondary ITP (SLE, HIV, HCV, drugs)",
        "Drug-induced immune thrombocytopenia (DITP)",
        "Heparin-induced thrombocytopenia (HIT) — THROMBOSIS, not just bleeding",
        "Post-transfusion purpura (PTP)",
        "Alloimmune thrombocytopenia (neonatal)",
    ]),
    ("Increased Destruction — NON-IMMUNE (Microangiopathic)", AMBER, AMBER_LIGHT, [
        "TTP (Thrombotic Thrombocytopenic Purpura) — MAHA + neuro symptoms",
        "HUS (Haemolytic Uraemic Syndrome) — MAHA + renal failure",
        "DIC — consumption coagulopathy",
        "Preeclampsia / HELLP syndrome",
        "Antiphospholipid syndrome",
    ]),
    ("Decreased Platelet Production", PURPLE, PURPLE_LIGHT, [
        "Aplastic anaemia",
        "Myelodysplastic syndrome (MDS)",
        "Acute leukaemia / bone marrow infiltration",
        "B12/folate deficiency (macrocytic anaemia + thrombocytopenia)",
        "Alcohol-induced bone marrow suppression",
        "Chemotherapy / radiation",
    ]),
    ("Sequestration / Redistribution", BLUE, BLUE_LIGHT, [
        "Hypersplenism (any cause of splenomegaly)",
        "Chronic liver disease / portal hypertension",
        "Gaucher's disease",
        "Hypothermia (reversible splenic pooling)",
    ]),
    ("Hereditary / Congenital Causes", GREEN, GREEN_LIGHT, [
        "MYH9-related disorders (May-Hegglin anomaly) — giant platelets",
        "Bernard-Soulier syndrome",
        "Wiskott-Aldrich syndrome (X-linked)",
        "Fanconi anaemia — pancytopenia",
        "Congenital amegakaryocytic thrombocytopenia",
    ]),
]

positions = [(0.45, 1.12), (6.8, 1.12), (0.45, 3.98), (6.8, 3.98), (0.45, 6.08)]
widths = [6.1, 6.1, 6.1, 6.1, 12.45]
heights = [2.7, 2.7, 1.9, 1.9, 1.25]
for (x, y), w, h, (title, acc, bg, items) in zip(positions, widths, heights, diffs):
    section_card(s, title, x, y, w, h, acc, bg)
    bullets(s, items, x+0.12, y+0.42, w-0.22, h-0.46, sz=11.5)

# ═══════════════════════════════════════════════════════════
# SLIDE 11 — Investigations
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Investigations in ITP",
           "Goal: exclude secondary causes · Confirm isolated thrombocytopenia")

# Table format
headers = ["Investigation", "Findings in Primary ITP", "Significance"]
col_x = [0.45, 4.3, 9.1]
col_w = [3.8, 4.75, 4.05]
rect(s, 0.45, 1.12, 12.45, 0.46, DEEP_TEAL)
for j, (hdr, x, w) in enumerate(zip(headers, col_x, col_w)):
    txt(s, hdr, x+0.08, 1.14, w-0.1, 0.42, sz=13, bold=True,
        color=WHITE, va=MSO_ANCHOR.MIDDLE)

rows = [
    ("CBC", "Isolated ↓ platelets; WBC + Hb NORMAL", "Other cytopenias → secondary cause"),
    ("Peripheral Blood Smear", "Large (young) platelets; RBC + WBC morphology normal", "Fragmented RBCs → TTP/HUS; blasts → leukaemia; clumps → pseudo"),
    ("Coagulation (PT, aPTT)", "NORMAL", "Prolonged → DIC, liver disease, anticoagulant effect"),
    ("HIV serology", "Exclude HIV-associated ITP", "HIV directly causes thrombocytopenia; alters treatment"),
    ("HCV / HBV serology", "Exclude viral hepatitis", "HCV common cause secondary ITP; HBV: avoid rituximab unless covered"),
    ("ANA / anti-dsDNA", "Negative in primary ITP", "Positive → SLE (secondary ITP)"),
    ("APLA screen", "Negative in primary ITP", "Antiphospholipid syndrome causes both thrombocytopenia AND thrombosis"),
    ("Direct Antiglobulin Test (DAT)", "Negative in primary ITP", "Positive + haemolytic anaemia → Evans' syndrome"),
    ("Serum immunoglobulins / SPEP", "Normal", "Hypogammaglobulinaemia, monoclonal protein → lymphoproliferative disorder"),
    ("H. pylori testing", "Positive in endemic areas (~20%)", "Eradication may improve platelets; geographic variation in benefit"),
    ("Anti-platelet antibodies", "Low sensitivity & specificity — NOT routinely recommended", "Poor diagnostic yield; negative result does not exclude ITP"),
    ("Bone Marrow Examination", "Normal or ↑ megakaryocytes (large, immature)", "Reserved for atypical cases, failure of 1st-line Rx, age >60, pre-splenectomy"),
    ("Serum TPO level", "Normal or mildly elevated (paradoxically NOT high)", "Distinguishes from aplastic anaemia / bone marrow failure (where TPO is very high)"),
]
for i, (inv, find, sig) in enumerate(rows):
    yp = 1.6 + i * 0.42
    bg = TEAL_LIGHT if i % 2 == 0 else WHITE
    rect(s, 0.45, yp, 12.45, 0.42, bg)
    for j, (cell, x, w) in enumerate(zip([inv, find, sig], col_x, col_w)):
        bld = j == 0
        col = DEEP_TEAL if bld else DARK_TEXT
        txt(s, cell, x+0.06, yp+0.03, w-0.1, 0.36, sz=11.5, bold=bld,
            color=col, va=MSO_ANCHOR.MIDDLE)

# ═══════════════════════════════════════════════════════════
# SLIDE 12 — First-Line Treatment
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "Treatment — First-Line Therapy",
           "Goal: safe platelet count (≥30 × 10⁹/L) · Minimise treatment toxicity")

# When to treat decision
rect(s, 0.45, 1.12, 12.45, 1.15, AMBER_LIGHT, line=True)
rect(s, 0.45, 1.12, 0.07, 1.15, AMBER)
txt(s, "When to Treat? (ASH 2019 Guidelines)", 0.62, 1.14, 12.0, 0.42, sz=13, bold=True, color=AMBER)
when = "Platelets <30 × 10⁹/L with active bleeding  |  Platelets <20 × 10⁹/L (even asymptomatic) → consider treatment  |  " \
       "Patients with significant bleeding risk (surgery, anticoagulation, lifestyle)  |  " \
       "Patients with platelet >30 × 10⁹/L who are ASYMPTOMATIC → observation only (no treatment needed)"
txt(s, when, 0.62, 1.58, 12.1, 0.62, sz=12.5, color=DARK_TEXT)

# Treatment agents
agents = [
    ("Corticosteroids\n(First Choice)", "MECHANISM: ↓ FcγR-mediated phagocytosis + ↓ antibody synthesis + ↑ platelet production\n\n"
     "REGIMENS:\n• Dexamethasone 40 mg/day PO/IV × 4 days (preferred — faster response)\n"
     "• Prednisone 1 mg/kg/day with gradual taper over 4–6 weeks\n\n"
     "RESPONSE: 70–80% initial response rate; however 30–40% relapse\n\n"
     "SIDE EFFECTS: Hyperglycaemia, hypertension, insomnia, psychosis, osteoporosis,\n"
     "weight gain, immunosuppression — limit long-term use",
     DEEP_TEAL, TEAL_LIGHT),
    ("IVIG — Intravenous\nImmunoglobulin", "MECHANISM: Saturates FcγRs on macrophages → temporarily blocks platelet destruction\n\n"
     "DOSE: 1 g/kg × 1–2 days (total 1–2 g/kg)\n\n"
     "USE: Rapid platelet rise needed — surgery, active severe bleeding, pre-procedure\n"
     "Used with steroids for platelet counts <10 × 10⁹/L or significant bleeding\n\n"
     "ONSET: 24–48 h  |  DURATION: 2–6 weeks (temporary!)\n\n"
     "SIDE EFFECTS: Headache, fever, hypertension, aseptic meningitis, thromboembolism, renal failure (sucrose-based preparations)",
     MED_TEAL, TEAL_LIGHT),
    ("Anti-D\nImmunoglobulin\n(Rh₀ immune globulin)", "MECHANISM: Limited haemolysis of antibody-coated RBCs saturates FcγRs → blocks platelet destruction\n\n"
     "DOSE: 50–75 μg/kg IV\n\n"
     "ONLY in: Rh-positive, non-splenectomised patients\n\n"
     "FDA BLACK BOX WARNING: Severe intravascular haemolysis (rare) → 8h post-infusion monitoring mandatory\n\n"
     "NOTE: Less commonly used now given available safer alternatives; ineffective post-splenectomy",
     AMBER, AMBER_LIGHT),
]
for i, (name, desc, accent, bg) in enumerate(agents):
    x = 0.45 + i*4.29
    rect(s, x, 2.37, 4.22, 0.46, accent)
    txt(s, name, x+0.1, 2.39, 4.0, 0.42, sz=13, bold=True,
        color=WHITE, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE)
    rect(s, x, 2.83, 4.22, 4.52, bg, line=True)
    txt(s, desc, x+0.12, 2.87, 3.98, 4.44, sz=11.5, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════
# SLIDE 13 — Second-Line: Rituximab & TPO-RAs
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Treatment — Second-Line: Rituximab & TPO-Receptor Agonists",
           "For persistent/chronic ITP unresponsive to 1st-line · Preferred over early splenectomy")

# When second-line
rect(s, 0.45, 1.12, 12.45, 0.72, AMBER_LIGHT, line=True)
rect(s, 0.45, 1.12, 0.07, 0.72, AMBER)
txt(s, "Indications for Second-Line Therapy", 0.62, 1.15, 12.0, 0.38, sz=13, bold=True, color=AMBER)
txt(s, "Relapsed or refractory after 1st-line steroids (30–40% of adults)  |  "
       "Steroid-dependent  |  Steroid intolerance/contraindication  |  Persistent ITP (3–12 months)  |  "
       "Chronic ITP >12 months — currently ASH recommends TPO-RA or rituximab over early splenectomy",
    0.62, 1.55, 12.1, 0.24, sz=12, color=DARK_TEXT)

# Rituximab column
section_card(s, "RITUXIMAB (Anti-CD20 Monoclonal Antibody)", 0.45, 1.95, 6.0, 5.4, BLUE, BLUE_LIGHT)
ritu = [
    (0, "TARGET: CD20 on B cells → B-cell depletion → ↓ autoantibody production", False),
    (0, "DOSE: 375 mg/m² IV weekly × 4 doses (standard) OR 100 mg/m² low-dose × 4 weekly doses", False),
    (0, "RESPONSE RATES:", True),
    (1, "Initial response: ~60% of patients", False),
    (1, "Sustained response at 1 year: ~40%", False),
    (1, "Durable complete response at 5 years: ~20–30%", False),
    (0, "ONSET: 4–8 weeks (NOT for urgent/emergency treatment)", False),
    (0, "Re-treatment: retreatment possible if relapse; some patients respond again", False),
    (0, "SIDE EFFECTS:", True),
    (1, "Infusion reactions (pre-medicate with steroids/antihistamines)", False),
    (1, "Hypogammaglobulinaemia (check IgG levels pre-/post-treatment)", False),
    (1, "HBV reactivation → screen ALL patients for HBV before treatment; prophylactic antivirals if HBsAg+ or anti-HBc+", False),
    (1, "Progressive multifocal leukoencephalopathy (PML) — rare but reported", False),
    (1, "Prolonged B-cell depletion: 6–12 months", False),
    (0, "NOT FDA-approved for ITP but widely used off-label (evidence from multiple RCTs)", False),
]
bullets(s, ritu, 0.55, 2.38, 5.8, 4.85, sz=12)

# TPO-RA column
section_card(s, "TPO-RECEPTOR AGONISTS (TPO-RA)", 6.75, 1.95, 6.15, 5.4, PURPLE, PURPLE_LIGHT)
tpo = [
    (0, "MECHANISM: Mimic endogenous TPO → bind c-Mpl receptor on megakaryocytes → ↑ platelet production", False),
    (0, "THREE APPROVED TPO-RAs (all FDA-approved for chronic ITP):", True),
    (1, "ROMIPLOSTIM (Nplate): SC injection weekly; peptibody; 1–10 μg/kg/week; dose-titrated", False),
    (1, "ELTROMBOPAG (Promacta): oral once daily; 25–75 mg; small molecule non-peptide", False),
    (1, "AVATROMBOPAG (Doptelet): oral once daily; 20–40 mg; newest agent", False),
    (0, "RESPONSE RATES:", True),
    (1, "Durable platelet improvement in >90% of patients", False),
    (1, "Response onset: 5–14 days", False),
    (1, "10–30% maintain durable response even after stopping therapy", False),
    (0, "ADVANTAGES over splenectomy/rituximab: maintained on long-term with good efficacy; can reduce/stop other therapies", False),
    (0, "SIDE EFFECTS:", True),
    (1, "Thromboembolic events (DVT, PE, portal vein thrombosis) — monitor for symptoms", False),
    (1, "Bone marrow reticulin fibrosis (rare; romiplostim > eltrombopag) — monitor with BM biopsy if on long-term", False),
    (1, "Eltrombopag: hepatotoxicity (LFT monitoring required), avoid with antacids/calcium (chelation)", False),
    (1, "Rebound thrombocytopenia on abrupt withdrawal — taper carefully", False),
    (0, "NOTE: Fostamatinib (SYK inhibitor) and Inebilizumab/FcRn inhibitors: newer agents for refractory ITP", False),
]
bullets(s, tpo, 6.85, 2.38, 5.95, 4.85, sz=11.5)

# ═══════════════════════════════════════════════════════════
# SLIDE 14 — Splenectomy
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "Treatment — Splenectomy",
           "Historical gold standard · Now deferred to ≥12 months · ~80% initial response")

section_card(s, "Rationale & Timing", 0.45, 1.12, 6.0, 2.8, DEEP_TEAL, TEAL_LIGHT)
rat = [
    "Spleen: PRIMARY site of anti-platelet IgG production AND platelet destruction",
    "Removes both the 'factory' and the 'graveyard' of antibody-coated platelets",
    "ASH 2019: Defer splenectomy to ≥12 months (chronic ITP); allow time for medical therapy response",
    "Consider earlier if: life-threatening bleeding, failure of all medical therapies, patient preference to avoid long-term drugs",
    "Emergency splenectomy: reserved for life-threatening, medically refractory bleeding",
    "Pre-op: vaccination ≥2 weeks before surgery (pneumococcus, meningococcus, H. influenzae type b)",
]
bullets(s, rat, 0.55, 1.55, 5.8, 2.3, sz=12.5)

section_card(s, "Response Rates", 6.75, 1.12, 6.1, 2.8, GREEN, GREEN_LIGHT)
resp = [
    "INITIAL response rate: ~80% (immediate platelet rise post-operatively)",
    "LONG-TERM remission (no further treatment): ~60% at 5 years",
    "PARTIAL response (still need medical therapy): ~20%",
    "FAILURE / RELAPSE: ~20% — consider accessory spleen (5–7% of cases)",
    "Accessory spleen: excluded pre-operatively by technetium scan or CT",
    "Post-splenectomy: if relapse, check for missed accessory spleen",
]
bullets(s, resp, 6.85, 1.55, 5.9, 2.3, sz=12.5)

section_card(s, "Contraindications to Splenectomy", 0.45, 4.02, 6.0, 1.95, CRIMSON, CRIMSON_LIGHT)
contra = [
    "Newly diagnosed ITP (< 3–6 months)",
    "Adequate response to medical therapy",
    "High surgical risk (severe comorbidities)",
    "Pregnancy (relative; can be done in 2nd trimester if life-threatening)",
    "Severe bleeding disorder not yet controlled",
]
bullets(s, contra, 0.55, 4.45, 5.8, 1.48, sz=12.5)

section_card(s, "Post-Splenectomy Care & Risks", 6.75, 4.02, 6.1, 1.95, AMBER, AMBER_LIGHT)
post = [
    "OPSI (Overwhelming Post-Splenectomy Infection): lifelong risk; most common in first 2 years",
    "Causative organisms: S. pneumoniae, N. meningitidis, H. influenzae",
    "VACCINATION: Pneumococcal (PCV13 + PPSV23), meningococcal, Hib, annual influenza",
    "PROPHYLACTIC ANTIBIOTICS: Penicillin V 250–500 mg BD (consider in first 2 years and asplenic)",
    "Educate: seek immediate medical attention for fever ≥38°C post-splenectomy",
]
bullets(s, post, 6.85, 4.45, 5.9, 1.48, sz=12.5)

# Approach algorithm bottom
rect(s, 0.45, 6.05, 12.45, 1.35, WHITE, line=True)
rect(s, 0.45, 6.05, 0.07, 1.35, DEEP_TEAL)
txt(s, "Current Preferred Treatment Sequence (ASH 2019)", 0.62, 6.08, 12.0, 0.42, sz=13, bold=True, color=DEEP_TEAL)
txt(s, "Newly Diagnosed → Corticosteroids ± IVIG  →  Persistent/Chronic: TPO-RA or Rituximab  →  Splenectomy only if refractory/chronic (>12 months)  →  Refractory post-splenectomy: novel agents (fostamatinib, FcRn inhibitors)",
    0.62, 6.52, 12.1, 0.78, sz=12.5, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════
# SLIDE 15 — Emergency Management
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Emergency Management — Severe / Life-Threatening ITP",
           "Platelet <10 × 10⁹/L + active bleeding · Target platelet ≥50–100 × 10⁹/L urgently")

rect(s, 0.45, 1.12, 12.45, 0.6, CRIMSON_LIGHT, line=True)
rect(s, 0.45, 1.12, 0.07, 0.6, CRIMSON)
txt(s, "Indications for Emergency Treatment", 0.62, 1.15, 12.0, 0.3, sz=13, bold=True, color=CRIMSON)
txt(s, "ICH / intracranial haemorrhage  |  Retinal haemorrhage  |  Wet purpura + platelet <10 × 10⁹/L  |  Major GI/GU bleed  |  "
       "Haemodynamic instability  |  Pre-emergency surgery  |  Platelet <5 × 10⁹/L (any circumstance)",
    0.62, 1.47, 12.1, 0.2, sz=12, color=DARK_TEXT)

# Cascade
steps_emg = [
    ("IMMEDIATE", "High-dose IV methylprednisolone 1000 mg/day × 3 days\nOR Dexamethasone 40 mg IV × 4 days", CRIMSON),
    ("+", "IVIG 1 g/kg IV (repeat if needed); consider 2nd dose at 24–48 h if inadequate response", MED_TEAL),
    ("+", "PLATELET TRANSFUSION: Not standard in ITP (antibodies destroy transfused platelets too)\n"
          "BUT: use for life-threatening bleeding (ICH) — give in high doses; short-lived effect; combined with IVIG",
     AMBER),
    ("+", "Anti-D immunoglobulin 75 μg/kg (if Rh+, non-splenectomised, Hb adequate)", BLUE),
    ("+", "TPO-RA (eltrombopag or romiplostim): start ASAP — takes 5–14 days to work; bridge with above agents", PURPLE),
    ("If no\nresponse", "Consider: Rituximab high-dose  |  Recombinant factor VIIa (rFVIIa)  |  Vincristine  |  Danazol\n"
                        "EMERGENCY SPLENECTOMY as last resort for refractory life-threatening bleeding",
     DEEP_TEAL),
]
y_s = 1.82
for label, desc, accent in steps_emg:
    h = 0.78 if len(desc) > 120 else 0.65
    rect(s, 0.45, y_s, 1.5, h, accent)
    txt(s, label, 0.48, y_s+0.04, 1.44, h-0.08, sz=12.5, bold=True,
        color=WHITE, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE)
    rect(s, 1.98, y_s, 11.0, h, LIGHT_GRAY if y_s % 2 > 1 else WHITE, line=True)
    txt(s, desc, 2.08, y_s+0.04, 10.8, h-0.08, sz=12, color=DARK_TEXT)
    y_s += h + 0.06

# ═══════════════════════════════════════════════════════════
# SLIDE 16 — Special Populations
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
header_bar(s, "ITP in Special Populations",
           "Paediatric · Pregnancy · Elderly · HIV-associated")

pops = [
    ("ITP IN CHILDREN", DEEP_TEAL, TEAL_LIGHT, [
        "Acute, post-viral (1–3 weeks after viral illness / vaccine)",
        "Platelet <20 × 10⁹/L common, >80% spontaneous remission within weeks–months",
        "Management: observation if mild bleeding (skin only) even with platelet <20 × 10⁹/L",
        "Treatment when needed: IVIG 0.8–1 g/kg, prednisone, or anti-D",
        "AVOID routine bone marrow biopsy unless atypical features or failure of 1st-line",
        "Splenectomy deferred until >12 months; very rarely needed in children",
        "Re-evaluate at 12 months — if platelet <20 or significant symptoms → chronic ITP treatment",
    ]),
    ("ITP IN PREGNANCY", AMBER, AMBER_LIGHT, [
        "Incidence: ~1 in 1,000–10,000 pregnancies — must distinguish from gestational thrombocytopenia (GT)",
        "GT: Platelet rarely <70 × 10⁹/L; 1st/2nd trimester decline; no neonatal thrombocytopenia",
        "ITP: pre-existing or new diagnosis; neonatal thrombocytopenia risk (<10 × 10⁹/L) in ~10% neonates",
        "Treatment: Prednisolone 10–20 mg/day; IVIG 1 g/kg; target platelet ≥30 (T1/T2), ≥50 (T3), ≥80 (neuraxial anaesthesia)",
        "AVOID: anti-D (risk to Rh+ foetus), azathioprine (teratogenic), mycophenolate, cyclophosphamide",
        "H. pylori eradication: defer until after delivery",
        "Mode of delivery: vaginal delivery preferred; Caesarean for obstetric indications only",
        "Neonates: check platelet count at birth; monitor if <50 × 10⁹/L",
    ]),
    ("ITP IN HIV", PURPLE, PURPLE_LIGHT, [
        "HIV directly infects megakaryocytes → ↓ production; also immune-mediated destruction",
        "HAART (antiretroviral therapy) is first-line — often improves platelet count",
        "Avoid immunosuppression (steroids) if CD4 <200 cells/μL",
        "IVIG: safe and effective bridge therapy",
        "Splenectomy: effective but increases risk of opportunistic infections — only for refractory cases",
        "TPO-RAs: effective and generally safe; preferred in HIV-ITP",
    ]),
    ("ELDERLY PATIENTS", BLUE, BLUE_LIGHT, [
        "More complex presentation — comorbidities, polypharmacy (drug-induced ITP common)",
        "Higher risk of both bleeding AND treatment complications",
        "Steroid side effects exacerbated: diabetes, hypertension, osteoporosis, delirium",
        "TPO-RAs: preferred over steroids or splenectomy where possible",
        "Thromboembolism risk higher with TPO-RA — monitor closely",
        "Secondary ITP more common (MDS, lymphoma) — BM biopsy lower threshold",
    ]),
]

positions = [(0.45, 1.12), (6.8, 1.12), (0.45, 4.28), (6.8, 4.28)]
widths2 = [6.1, 6.1, 6.1, 6.1]
heights2 = [3.0, 3.0, 3.07, 3.07]
for (x, y), w, h, (title, acc, bg, items) in zip(positions, widths2, heights2, pops):
    section_card(s, title, x, y, w, h, acc, bg)
    bullets(s, items, x+0.12, y+0.42, w-0.22, h-0.46, sz=11.5)

# ═══════════════════════════════════════════════════════════
# SLIDE 17 — Monitoring & Follow-up
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, WHITE)
header_bar(s, "Monitoring & Follow-up",
           "Tailored by disease phase, treatment, and bleeding risk")

# Phases table
phases_mon = [
    ("NEWLY DIAGNOSED\n(0–3 months)", "• CBC weekly initially, then every 2 weeks\n"
     "• Assess bleeding symptoms at each visit\n• Monitor steroid side effects (glucose, BP, weight)\n"
     "• Document treatment response\n• Screen for secondary causes (HIV, HCV, ANA if not done)\n"
     "• TARGET: Platelet ≥30 × 10⁹/L safely", DEEP_TEAL, TEAL_LIGHT),
    ("PERSISTENT ITP\n(3–12 months)", "• CBC every 4 weeks during treatment\n"
     "• Reassess: Is treatment still needed?\n• Consider 2nd-line if relapsed or steroid-dependent\n"
     "• Start TPO-RA or rituximab if persistent symptoms\n"
     "• Patient education: bleeding precautions, emergency contact\n"
     "• Avoid NSAIDs, antiplatelet drugs", AMBER, AMBER_LIGHT),
    ("CHRONIC ITP\n(>12 months)", "• CBC every 4–12 weeks (depending on stability)\n"
     "• Annual reassessment of treatment need\n• Long-term TPO-RA: LFTs (eltrombopag), bone marrow reticulin monitoring\n"
     "• Splenectomy discussion if refractory + patient preference\n"
     "• Vaccinations if splenectomy planned\n• Bone density monitoring if long-term steroids", PURPLE, PURPLE_LIGHT),
    ("ON TPO-RAs\n(Maintenance)", "• CBC weekly for first month → monthly when stable\n"
     "• Eltrombopag: LFTs monthly initially; avoid dairy/antacids (chelation)\n"
     "• Romiplostim: weekly CBC; dose adjustment by response\n"
     "• Monitor for thromboembolic symptoms\n"
     "• If platelet >400 × 10⁹/L → dose reduction\n"
     "• Attempt TPO-RA taper when platelet stable ≥100 × 10⁹/L", GREEN, GREEN_LIGHT),
    ("POST-SPLENECTOMY", "• CBC weekly × 4 weeks post-op, then monthly × 3 months, then quarterly\n"
     "• Assess for OPSI: educate patient; medical alert bracelet\n"
     "• Booster vaccinations per schedule (pneumococcal every 5 years)\n"
     "• If relapse: check accessory spleen (Tc-99m scan/CT)\n"
     "• Monitor for rebound thrombocytosis (platelet >1000 × 10⁹/L) — transient, rarely thrombogenic", CRIMSON, CRIMSON_LIGHT),
    ("REMISSION / OFF\nTHERAPY", "• CBC every 6–12 months\n"
     "• Recheck if any bleeding symptoms develop\n"
     "• Educate: avoid NSAIDs/antiplatelet agents\n"
     "• Maintain immunisations current\n"
     "• Reassess if any new illness, medication change, or pregnancy planned\n"
     "• Low threshold to re-check platelet if viral illness / new drug started", BLUE, BLUE_LIGHT),
]

for i, (phase, plan, acc, bg) in enumerate(phases_mon):
    col = i % 2; row = i // 2
    x = 0.45 + col * 6.45; y = 1.12 + row * 2.1
    w = 6.05; h = 1.95
    section_card(s, phase, x, y, w, h, acc, bg)
    txt(s, plan, x+0.12, y+0.42, w-0.22, h-0.46, sz=11, color=DARK_TEXT)

# ═══════════════════════════════════════════════════════════
# SLIDE 18 — Key Take-Home Messages
# ═══════════════════════════════════════════════════════════
s = prs.slides.add_slide(blank)
rect(s, 0, 0, 13.333, 7.5, OFF_WHITE)
rect(s, 0, 0, 13.333, 1.0, DEEP_TEAL)
rect(s, 0, 1.0, 13.333, 0.06, MED_TEAL)
txt(s, "Key Take-Home Messages", 0.3, 0.08, 12.8, 0.84,
    sz=30, bold=True, color=WHITE, va=MSO_ANCHOR.MIDDLE)

msgs = [
    ("1", "ITP is immune-mediated DUAL pathology: platelet destruction + impaired production. TPO-RAs address both.", DEEP_TEAL, TEAL_LIGHT),
    ("2", "ITP is a DIAGNOSIS OF EXCLUSION. Always exclude pseudothrombocytopenia (check smear) and secondary causes (HIV, HCV, SLE, drugs).", BLUE, BLUE_LIGHT),
    ("3", "Treat when platelet <30 × 10⁹/L or <20 × 10⁹/L asymptomatically. Platelet ≥30 without bleeding = observe.", AMBER, AMBER_LIGHT),
    ("4", "Wet purpura (oral haemorrhagic bullae) + retinal haemorrhages = EMERGENCY. Admit, combined-modality treatment immediately.", CRIMSON, CRIMSON_LIGHT),
    ("5", "Children: >80% spontaneous remission — avoid aggressive early treatment. Adults: chronic disease; relapse common.", GREEN, GREEN_LIGHT),
    ("6", "ASH 2019: Prefer TPO-RA or rituximab over early splenectomy. Defer splenectomy to ≥12 months.", PURPLE, PURPLE_LIGHT),
    ("7", "Before rituximab: screen ALL patients for HBV. Administer prophylactic antivirals if HBsAg+ or anti-HBc+.", MED_TEAL, TEAL_LIGHT),
    ("8", "Post-splenectomy: vaccinate ≥2 weeks pre-op; life-long OPSI risk; educate on fever emergency protocol.", AMBER, AMBER_LIGHT),
]

for i, (num, msg, acc, bg) in enumerate(msgs):
    col = i % 2; row = i // 2
    x = 0.45 + col * 6.45; y = 1.14 + row * 1.52
    w = 6.05; h = 1.42
    rect(s, x, y, w, h, bg, line=True)
    rect(s, x, y, 0.55, h, acc)
    txt(s, num, x, y+0.02, 0.55, h-0.04, sz=24, bold=True,
        color=WHITE, align=PP_ALIGN.CENTER, va=MSO_ANCHOR.MIDDLE)
    txt(s, msg, x+0.62, y+0.1, w-0.7, h-0.2, sz=12.5, color=DARK_TEXT, va=MSO_ANCHOR.MIDDLE)

txt(s, "Sources: Harrison's 22e (2025) · Goldman-Cecil Medicine · Washington Manual · Rosen's EM · Sabiston Surgery · Fischer's Mastery of Surgery",
    0.45, 7.2, 12.45, 0.25, sz=10, italic=True, color=MED_TEXT, align=PP_ALIGN.CENTER)

# ─── SAVE ──────────────────────────────────────────────────
out = "/tmp/workspace/itp-presentation/ITP_Postgraduate_IM.pptx"
prs.save(out)
print(f"Saved: {out}")
print(f"Slides: {len(prs.slides)}")