2024 WHO hepatitis B chronic infection guidelines treatment eligibility adults

hepatitis B management

https://www.who.int/publications/i/item/9789240090903

hepatitis B virus serology antigen antibody time course diagram HBsAg HBeAg anti-HBc anti-HBs

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AASLD 2025 practice guideline chronic hepatitis B treatment recommendations adults treatment indications

mkdir -p /tmp/workspace/hepatitis-b-presentation/src /tmp/workspace/hepatitis-b-presentation/output && python - <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.dml.color import RGBColor from pptx.enum.shapes import MSO_SHAPE from pptx.enum.text import PP_ALIGN, MSO_ANCHOR from pptx.enum.dml import MSO_THEME_COLOR from pptx.enum.text import MSO_AUTO_SIZE from pptx.enum.shapes import MSO_CONNECTOR from pptx.enum.text import MSO_VERTICAL_ANCHOR OUT='/tmp/workspace/hepatitis-b-presentation/output/Hepatitis_B_Postgraduate_iMed.pptx' prs=Presentation(); prs.slide_width=Inches(13.333); prs.slide_height=Inches(7.5) blank=prs.slide_layouts[6] # palette NAVY=RGBColor(12,40,72); BLUE=RGBColor(24,103,171); TEAL=RGBColor(0,137,123); RED=RGBColor(190,57,52); GOLD=RGBColor(218,160,40); LIGHT=RGBColor(243,247,250); MID=RGBColor(91,110,130); DARK=RGBColor(35,43,50); WHITE=RGBColor(255,255,255); PALE=RGBColor(225,238,247); GREEN=RGBColor(40,130,82); ORANGE=RGBColor(231,133,38) def rect(s,x,y,w,h,color, radius=False, line=None): sh=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if radius else MSO_SHAPE.RECTANGLE, Inches(x), Inches(y), Inches(w), Inches(h)); sh.fill.solid(); sh.fill.fore_color.rgb=color; sh.line.color.rgb=line if line else color; return sh def textbox(s,x,y,w,h,text,size=20,color=DARK,bold=False,align=PP_ALIGN.LEFT, font='Aptos', valign=MSO_ANCHOR.TOP): tb=s.shapes.add_textbox(Inches(x),Inches(y), Inches(w), Inches(h)); tf=tb.text_frame; tf.clear(); tf.word_wrap=True; tf.margin_left=Inches(.06); tf.margin_right=Inches(.05); tf.margin_top=Inches(.02); tf.margin_bottom=Inches(.02); tf.vertical_anchor=valign for i,line in enumerate(text.split('\n')): p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.text=line; p.alignment=align; p.space_after=Pt(4) for r in p.runs: r.font.name=font; r.font.size=Pt(size); r.font.bold=bold; r.font.color.rgb=color return tb def title(s, t, sub=None, n=None): rect(s,0,0,13.333,.18,TEAL); textbox(s,.55,.34,11.9,.48,t,28,NAVY,True) if sub: textbox(s,.58,.86,11.7,.28,sub,11,MID) if n is not None: textbox(s,12.2,.38,.55,.25,str(n),11,TEAL,True,PP_ALIGN.RIGHT) def bullets(s, items, x=.75,y=1.35,w=11.8,h=5.6,size=19, color=DARK): tb=s.shapes.add_textbox(Inches(x), Inches(y), Inches(w), Inches(h)); tf=tb.text_frame;tf.clear();tf.word_wrap=True;tf.margin_left=Inches(.1);tf.margin_top=Inches(.06) for i,item in enumerate(items): p=tf.paragraphs[0] if i==0 else tf.add_paragraph(); p.text=item; p.level=0; p.font.size=Pt(size); p.font.name='Aptos'; p.font.color.rgb=color; p.space_after=Pt(12); p.bullet=True return tb def footer(s, txt='Postgraduate Internal Medicine | Hepatitis B'): rect(s,.55,7.13,12.2,.012,RGBColor(190,205,215)); textbox(s,.56,7.18,8,.16,txt,8,MID) def notes(slide, text): try: tf=slide.notes_slide.notes_text_frame; tf.text=text except: pass def slide(t,sub=None): s=prs.slides.add_slide(blank); rect(s,0,0,13.333,7.5,WHITE); return s # 1 s=slide(); rect(s,0,0,13.333,7.5,NAVY); rect(s,0,0.0,13.333,.22,TEAL); textbox(s,.7,1.08,10.8,1.15,'Hepatitis B',42,WHITE,True); textbox(s,.74,2.35,10.7,.65,'Serology, investigations, treatment and treatment-start criteria',23,RGBColor(204,230,242)); textbox(s,.76,3.22,9.6,.4,'Postgraduate Internal Medicine teaching presentation',17,WHITE); rect(s,.74,4.05,4.55,.65,TEAL,True); textbox(s,.92,4.2,4.18,.2,'Focus: clinical decision making',14,WHITE,True,PP_ALIGN.CENTER); textbox(s,.76,6.57,10.6,.24,'Evidence framework: WHO 2024, AASLD/IDSA 2025, EASL 2025',11,RGBColor(180,207,224)); notes(s,'Use as a 35-45 minute structured teaching session. Confirm local policy before applying thresholds.') # 2 s=slide(); title(s,'Learning objectives',n=2); bullets(s,['Interpret the standard HBV serology panel, including the core window and isolated anti-HBc pattern.','Stage chronic HBV using virology, biochemical activity, fibrosis assessment and HCC risk.','Apply current WHO 2024 treatment eligibility criteria, while recognizing guideline-specific differences.','Select first-line therapy and plan monitoring, special-situation management and HCC surveillance.']); footer(s) #3 s=slide(); title(s,'Why HBV matters clinically',n=3); for x,h,lab,num,col in [(0.8,2.7,'Viral persistence', 'cccDNA',BLUE),(4.55,2.7,'Disease spectrum','Acute to HCC',TEAL),(8.3,2.7,'Decision variables','DNA + ALT + fibrosis',GOLD)]: rect(s,x,1.6,3.2,2.05,col,True);textbox(s,x+.18,1.88,2.84,.3,lab,18,WHITE,True,PP_ALIGN.CENTER);textbox(s,x+.18,2.47,2.84,.38,num,20,WHITE,False,PP_ALIGN.CENTER) bullets(s,['HBV is a DNA virus that replicates through reverse transcription. Nuclear cccDNA explains persistence and why nucleos(t)ide analogues suppress rather than usually eradicate infection.','Liver injury is largely immune mediated: HBV DNA alone does not quantify fibrosis or current necroinflammation.','Treatment aims: durable viral suppression, prevention of cirrhosis/decompensation/HCC, reduced transmission, and functional cure where achievable.'],.9,4.25,11.4,2.25,17); footer(s) #4 s=slide(); title(s,'Essential HBV markers: what each test answers',n=4) rows=[('HBsAg','Current infection; persistence >6 months defines chronic infection'),('Total anti-HBc','Prior exposure to HBV. Not produced by vaccination'),('IgM anti-HBc','Acute/recent infection; also possible during a chronic HBV flare/reactivation'),('Anti-HBs','Immunity after recovery or vaccine response'),('HBeAg / anti-HBe','Replication phenotype and relative infectivity, not a substitute for DNA'),('Quantitative HBV DNA','Direct measure of replication; essential for staging, treatment and response')] for i,(a,b) in enumerate(rows): y=1.28+i*.82; rect(s,.75,y,2.35,.62,PALE,True);textbox(s,.88,y+.14,2.05,.2,a,14,NAVY,True);textbox(s,3.35,y+.08,9.0,.43,b,15,DARK) footer(s); notes(s,'HBsAg may be falsely negative in rare occult infection or escape variants. DNA testing is decisive when there is diagnostic uncertainty.') #5 s=slide(); title(s,'Acute infection: time course and the core window',n=5) # axes s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT, Inches(1), Inches(5.85), Inches(12.3), Inches(5.85)).line.color.rgb=MID s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT, Inches(1), Inches(1.35), Inches(1), Inches(5.85)).line.color.rgb=MID textbox(s,.9,6.0,11.2,.22,'Exposure incubation symptoms / hepatitis convalescence',11,MID) # marker bars bars=[(1.35,2.0,5.0,RED,'HBV DNA'),(1.8,2.75,4.2,BLUE,'HBsAg'),(2.55,3.5,2.55,ORANGE,'HBeAg'),(3.0,4.45,2.0,GOLD,'IgM anti-HBc'),(4.3,5.2,6.35,TEAL,'anti-HBe'),(5.2,6.25,5.15,GREEN,'anti-HBs'),(3.2,5.9,3.3,NAVY,'ALT')] for y,x,w,c,l in bars: rect(s,x,y,w,.24,c,True);textbox(s,x+w+.08,y-.05,1.3,.22,l,11,c,True) rect(s,4.7,1.3,1.65,4.55,RGBColor(250,241,214),True,RGBColor(240,210,130));textbox(s,4.78,1.46,1.45,.55,'Core\nwindow',14,ORANGE,True,PP_ALIGN.CENTER);textbox(s,1.1,1.03,10.7,.2,'Only anti-HBc IgM may be positive after HBsAg disappears but before anti-HBs appears.',13,RED,True); footer(s) #6 s=slide(); title(s,'Interpretation of the screening serology panel',n=6) headers=['HBsAg','Total anti-HBc','Anti-HBs','Interpretation / next step']; x=[.65,2.15,4.15,6.1]; widths=[1.3,1.65,1.35,6.35] for i,h in enumerate(headers): rect(s,x[i],1.25,widths[i],.55,NAVY,True);textbox(s,x[i]+.04,1.4,widths[i]-.08,.16,h,12,WHITE,True,PP_ALIGN.CENTER) data=[('−','−','−','Susceptible - vaccinate'),('−','−','+','Immune after vaccination'),('−','+','+','Resolved infection - counsel re reactivation risk if immunosuppression'),('+','+','−','Current HBV infection - order DNA, HBeAg, ALT and stage liver'),('−','+','−','Isolated anti-HBc: consider resolved infection with waned anti-HBs, false positive, occult HBV, or window period')] for r,row in enumerate(data): y=1.9+r*.79; bg=LIGHT if r%2==0 else WHITE for i,val in enumerate(row): rect(s,x[i],y,widths[i],.68,bg,False,RGBColor(215,225,232));textbox(s,x[i]+.05,y+.16,widths[i]-.1,.3,val,13,DARK, i<3, PP_ALIGN.CENTER if i<3 else PP_ALIGN.LEFT) textbox(s,.75,6.2,11.8,.5,'Acute HBV: HBsAg positive + IgM anti-HBc positive. Chronic HBV: HBsAg persists for >6 months.',16,RED,True); footer(s) #7 s=slide(); title(s,'Isolated anti-HBc: a postgraduate diagnostic approach',n=7) steps=[('1. Verify','Repeat HBsAg, total anti-HBc and anti-HBs using a high-quality assay; review pretest probability.'),('2. Exclude acute HBV','Check IgM anti-HBc, ALT and symptoms. In the window period, IgM anti-HBc is positive.'),('3. Look for occult infection','Obtain sensitive HBV DNA, especially before immunosuppression, in HIV/HCV, dialysis, or unexplained liver disease.'),('4. Decide protection','It may represent remote resolved infection with waned anti-HBs. Vaccination strategy follows local policy and risk assessment.')] for i,(a,b) in enumerate(steps): y=1.22+i*1.25; rect(s,.75,y,2.1,.75,TEAL if i<2 else BLUE,True);textbox(s,.9,y+.22,1.8,.22,a,14,WHITE,True,PP_ALIGN.CENTER);textbox(s,3.1,y+.08,9.1,.54,b,16,DARK) textbox(s,.8,6.37,11.7,.34,'Do not label isolated anti-HBc as “immune” or “active HBV” without context and, when indicated, HBV DNA.',15,RED,True);footer(s) #8 s=slide(); title(s,'Chronic HBV: phenotype, not a simple “carrier state”',n=8) ph=[('HBeAg-positive chronic infection','High DNA, normal ALT, little activity; often younger'),('HBeAg-positive chronic hepatitis','High DNA + raised ALT; inflammation/fibrosis risk'),('HBeAg-negative chronic infection','Low DNA, normal ALT, inactive phenotype'),('HBeAg-negative chronic hepatitis','Fluctuating DNA/ALT; often precore/core-promoter variants')] for i,(a,b) in enumerate(ph): x=.75+(i%2)*6.1;y=1.35+(i//2)*2.15; rect(s,x,y,5.55,1.65,PALE if i%2==0 else LIGHT,True);textbox(s,x+.22,y+.2,5.05,.28,a,16,NAVY,True);textbox(s,x+.22,y+.7,5.0,.5,b,15,DARK) textbox(s,.78,6.2,11.7,.48,'Phenotypes can evolve. Serial ALT and HBV DNA are more informative than one time-point classification.',17,RED,True);footer(s) #9 s=slide(); title(s,'Baseline assessment in every HBsAg-positive adult',n=9) cols=[('Confirm and quantify',['Repeat HBsAg if needed','HBeAg / anti-HBe','Quantitative HBV DNA','Consider quantitative HBsAg where available']),('Assess liver disease',['ALT, AST, bilirubin, ALP','Albumin, INR, CBC/platelets','Creatinine/eGFR, phosphate','US liver ± elastography; APRI/FIB-4']),('Find modifiers',['HIV, HCV, HDV testing','HAV immunity; alcohol/metabolic risk','Family history of HCC/cirrhosis','Pregnancy status; planned immunosuppression'])] for i,(h,its) in enumerate(cols): x=.58+i*4.18; rect(s,x,1.35,3.78,4.85,PALE if i!=1 else RGBColor(234,245,241),True);textbox(s,x+.2,1.63,3.35,.3,h,18,NAVY,True,PP_ALIGN.CENTER);bullets(s,its,x+.22,2.28,3.28,3.4,15) footer(s);notes(s,'HDV testing is recommended at least once in people with chronic HBV in WHO 2024 guidance; exact national algorithms may vary.') #10 s=slide(); title(s,'Staging fibrosis and portal hypertension',n=10) bullets(s,['Use non-invasive tests first: transient elastography, APRI and FIB-4. Interpret cautiously during ALT flares, cholestasis or congestion because stiffness may be overestimated.','Evaluate for cirrhosis: thrombocytopenia, splenomegaly, nodular liver, elastography, synthetic dysfunction, varices. Liver biopsy is reserved for discordant or decision-changing cases.','For WHO 2024 eligibility, “significant fibrosis” can be defined by APRI >0.5 or transient elastography >7.0 kPa. These are treatment-access thresholds, not absolute histologic truths.','Cirrhosis changes the threshold: treat with detectable HBV DNA regardless of ALT; assess decompensation urgently.']); rect(s,.9,5.82,5.35,.72,NAVY,True);textbox(s,1.1,6.05,4.95,.2,'APRI = [(AST / AST ULN) × 100] / platelets (10⁹/L)',14,WHITE,True,PP_ALIGN.CENTER);footer(s) #11 s=slide(); title(s,'Treatment start: WHO 2024 simplified eligibility', 'Adults and adolescents ≥12 years with chronic HBV',11) items=[('1. Cirrhosis','Treat if HBV DNA is detectable, irrespective of ALT.'),('2. Significant fibrosis','Treat with APRI >0.5 or transient elastography >7.0 kPa, irrespective of HBV DNA/ALT in WHO simplified approach.'),('3. Immune-active disease','Treat if HBV DNA >2,000 IU/mL AND ALT ≥30 U/L (male) or ≥19 U/L (female).'),('4. Selected risk groups / comorbidity','Treat or strongly consider treatment with coinfection, immunosuppression, extrahepatic manifestations, family history of HCC/cirrhosis, or transmission-prevention indication.')] for i,(a,b) in enumerate(items): y=1.24+i*1.18;rect(s,.72,y,2.28,.8,[RED,ORANGE,TEAL,BLUE][i],True);textbox(s,.86,y+.17,1.98,.25,a,14,WHITE,True,PP_ALIGN.CENTER);textbox(s,3.23,y+.1,8.9,.52,b,16,DARK) textbox(s,.75,6.18,11.6,.45,'WHO broadens access. Confirm country programme criteria and interpret all criteria in the full clinical context.',14,RED,True);footer(s) #12 s=slide(); title(s,'Treatment initiation: compare common frameworks',n=12) headers=['Framework','Non-cirrhotic usual threshold','Cirrhosis','Key caveat']; widths=[2,4,2.2,3.5];xs=[.55,2.65,6.78,9.1] for i,h in enumerate(headers):rect(s,xs[i],1.3,widths[i],.52,NAVY,True);textbox(s,xs[i]+.04,1.43,widths[i]-.08,.16,h,12,WHITE,True,PP_ALIGN.CENTER) rows=[('WHO 2024','DNA >2,000 + ALT ≥30 M / ≥19 F; OR fibrosis threshold; risk groups','Detectable DNA','Simplified, access-focused algorithm'),('AASLD/IDSA 2025','HBeAg+: DNA ≥20,000; HBeAg−: ≥2,000 plus ALT activity/risk assessment','Treat','Shared decision making for grey zones'),('EASL 2025','Usually DNA ≥2,000 + ALT elevation and/or fibrosis','Treat','Broader individual risk assessment')] for r,row in enumerate(rows): y=1.95+r*1.25 for i,v in enumerate(row):rect(s,xs[i],y,widths[i],1.06,LIGHT if r%2==0 else WHITE,False,RGBColor(215,225,232));textbox(s,xs[i]+.08,y+.12,widths[i]-.16,.76,v,13,DARK,i==0) textbox(s,.7,5.9,11.7,.6,'Exam answer: state the guideline used, then give HBV DNA + ALT + fibrosis/cirrhosis + special-risk criteria. Do not treat a numerical cutoff as a substitute for staging.',16,RED,True);footer(s) #13 s=slide(); title(s,'When treatment is indicated irrespective of routine ALT-DNA pattern',n=13) items=[('Cirrhosis','Detectable HBV DNA: treat. Decompensated disease requires specialist care and indefinite high-barrier NA therapy.'),('Immunosuppression','Prevent HBV reactivation. Screen HBsAg and anti-HBc before therapy; prophylaxis strategy depends on drug risk and serostatus.'),('HIV coinfection','Use a fully suppressive antiretroviral regimen active against both HIV and HBV, typically tenofovir + lamivudine or emtricitabine.'),('Pregnancy / transmission prevention','Maternal HBV DNA >200,000 IU/mL: tenofovir prophylaxis in late pregnancy, plus birth-dose vaccine and HBIG for infant where indicated.'),('Extrahepatic disease','HBV-associated polyarteritis nodosa or glomerular disease: antiviral treatment in conjunction with specialist management.')] for i,(a,b) in enumerate(items): y=1.18+i*.99;rect(s,.7,y,2.3,.62,TEAL if i<3 else ORANGE,True);textbox(s,.83,y+.16,2.03,.18,a,13,WHITE,True,PP_ALIGN.CENTER);textbox(s,3.22,y+.06,9.1,.43,b,14,DARK) footer(s) #14 s=slide();title(s,'First-line pharmacotherapy',n=14) meds=[('Tenofovir disoproxil fumarate (TDF)','High barrier to resistance; preferred in pregnancy and HIV coinfection. Monitor renal function and bone risk.'),('Tenofovir alafenamide (TAF)','High barrier to resistance; less renal/bone toxicity than TDF. Availability and pregnancy data may limit use.'),('Entecavir (ETV)','High barrier in nucleoside-naive patients. Avoid as sole HBV agent in untreated HIV; dose-adjust in renal impairment.')] for i,(a,b) in enumerate(meds): y=1.35+i*1.45;rect(s,.75,y,3.0,.92,[BLUE,TEAL,NAVY][i],True);textbox(s,.92,y+.3,2.65,.22,a,15,WHITE,True,PP_ALIGN.CENTER);textbox(s,4.0,y+.15,8.2,.55,b,16,DARK) textbox(s,.8,5.95,11.5,.5,'Avoid lamivudine, adefovir and telbivudine as routine monotherapy because resistance or inferior potency is a concern. Pegylated interferon is selective, finite therapy but has contraindications and toxicity.',15,RED,True);footer(s) #15 s=slide(); title(s,'Before prescribing and during therapy',n=15) for x,h,its,col in [(.75,'Before start',['HBV DNA, ALT/AST, bilirubin','CBC, albumin, INR','eGFR ± phosphate; bone risk','HIV test before ETV monotherapy','Pregnancy and interactions'],BLUE),(4.62,'On treatment',['ALT, HBV DNA: assess virological response','Adherence and tolerability','TDF: renal function/phosphate','HCC surveillance if at risk','Do not stop abruptly without a plan'],TEAL),(8.49,'Expected response',['DNA suppression is primary endpoint','ALT normalization supports control','HBeAg seroconversion may occur','HBsAg loss is uncommon but ideal','Resistance uncommon with TDF/TAF/ETV'],GOLD)]: rect(s,x,1.4,3.45,4.85,PALE if col!=GOLD else RGBColor(252,246,226),True);textbox(s,x+.18,1.68,3.1,.3,h,18,NAVY,True,PP_ALIGN.CENTER);bullets(s,its,x+.2,2.3,3.0,3.55,14) footer(s) #16 s=slide();title(s,'Stopping nucleos(t)ide analogue therapy: do not oversimplify',n=16) bullets(s,['Most patients with cirrhosis, decompensation, HIV coinfection, or ongoing high-risk immunosuppression require long-term, often indefinite, therapy.','For non-cirrhotic patients, stopping rules differ by HBeAg status, prior seroconversion, duration of suppression and guideline. HBsAg loss is the safest finite-therapy endpoint.','Stopping may trigger severe hepatitis flare and hepatic decompensation. It requires reliable follow-up with frequent ALT and HBV DNA testing, especially in the first year.','Never discontinue tenofovir or another HBV-active drug in HIV coinfection without replacing HBV activity in the antiretroviral regimen.']);footer(s) #17 s=slide();title(s,'Acute hepatitis B management',n=17) bullets(s,['Most immunocompetent adults receive supportive care: hydration, antiemetics, avoid alcohol/hepatotoxins, assess severity and provide counseling on transmission.','Measure bilirubin, INR, glucose, mental status and renal function. Acute liver failure requires urgent transplant-center referral.','Antiviral therapy is generally reserved for severe, protracted or fulminant acute HBV, preferably with a high-potency, high-resistance-barrier NA.','Follow HBsAg and anti-HBs at 6 months to determine clearance versus chronic infection.']);rect(s,.8,5.85,11.5,.58,RGBColor(253,234,232),True,RED);textbox(s,1.0,6.04,11.1,.2,'Red flags: INR ≥1.5, encephalopathy, rapidly rising bilirubin, hypoglycemia, acute kidney injury, or clinical deterioration.',15,RED,True,PP_ALIGN.CENTER);footer(s) #18 s=slide();title(s,'HCC surveillance and longitudinal follow-up',n=18) bullets(s,['Ultrasound with or without AFP every 6 months for cirrhosis and other high-risk groups according to local HCC guidance. Antiviral suppression reduces but does not eliminate HCC risk.','Common high-risk non-cirrhotic groups include men from endemic regions over 40 years, women from endemic regions over 50 years, people with family history of HCC, Africans at younger age, and selected validated risk-score groups.','In untreated chronic HBV, repeat ALT and HBV DNA at intervals based on phenotype. A single normal ALT does not establish inactive infection.','Screen, vaccinate and counsel household/sexual contacts. Avoid sharing needles, razors or toothbrushes; use barrier protection until partners are immune.']);footer(s) #19 s=slide();title(s,'Clinical application: work through the data',n=19) rect(s,.8,1.28,11.6,1.25,PALE,True);textbox(s,1.05,1.5,11.1,.7,'38-year-old man: HBsAg positive for 9 months, HBeAg negative, HBV DNA 18,000 IU/mL, ALT 52 U/L (ULN 40), platelets 170 × 10⁹/L, elastography 8.2 kPa.',17,NAVY,True) qs=['1. Is this chronic HBV?','2. Is there evidence of activity?','3. Is fibrosis clinically relevant?','4. Does he meet WHO 2024 treatment eligibility?'] for i,q in enumerate(qs): y=3.05+i*.67;rect(s,1.05,y,10.9,.47,WHITE,True,RGBColor(185,205,218));textbox(s,1.28,y+.11,10.5,.18,q,15,DARK,True) textbox(s,.95,5.95,11.5,.62,'Answer: Yes. Persistent HBsAg confirms chronicity; DNA >2,000 with elevated ALT meets immune-active criterion, and elastography >7 kPa supports significant fibrosis. Start a high-barrier NA after complete baseline assessment.',16,RED,True);footer(s) #20 s=slide();title(s,'Exam-ready treatment-start algorithm',n=20) # flow boxes flow=[(5.0,.95,3.25,.62,'HBsAg positive >6 months?',NAVY),(5.0,1.95,3.25,.62,'Assess: HBV DNA + ALT + fibrosis\n+ cirrhosis + special risks',BLUE),(.85,3.35,3.1,.82,'Cirrhosis + detectable DNA',RED),(5.1,3.35,3.1,.82,'Fibrosis: APRI >0.5 or TE >7 kPa',ORANGE),(9.35,3.35,3.1,.82,'DNA >2,000 + ALT ≥30 M / ≥19 F',TEAL),(5.0,5.05,3.25,.82,'Treat with TDF / TAF / ETV\nthen monitor response and HCC risk',GREEN)] for x,y,w,h,txt,c in flow:rect(s,x,y,w,h,c,True);textbox(s,x+.12,y+.15,w-.24,h-.18,txt,14,WHITE,True,PP_ALIGN.CENTER, valign=MSO_ANCHOR.MIDDLE) for x1,y1,x2,y2 in [(6.62,1.57,6.62,1.95),(6.62,2.57,2.4,3.35),(6.62,2.57,6.65,3.35),(6.62,2.57,10.9,3.35),(2.4,4.17,6.62,5.05),(6.65,4.17,6.62,5.05),(10.9,4.17,6.62,5.05)]: ln=s.shapes.add_connector(MSO_CONNECTOR.STRAIGHT,Inches(x1), Inches(y1), Inches(x2), Inches(y2));ln.line.color.rgb=MID;ln.line.width=Pt(1.5) textbox(s,.8,6.35,11.8,.33,'Also treat/consider treatment for selected risk groups: immunosuppression, coinfection, extrahepatic disease, family history and prevention of vertical transmission.',14,RED,True,PP_ALIGN.CENTER);footer(s) #21 s=slide();title(s,'Take-home messages',n=21) for i,txt in enumerate(['Serology becomes clinically useful only when interpreted as a pattern, not as isolated results.','HBV DNA measures replication. ALT measures current injury imperfectly. Fibrosis and cirrhosis determine prognosis and lower the treatment threshold.','WHO 2024 makes treatment access simpler: fibrosis, immune-active disease, cirrhosis, and selected special-risk groups are the core pathways.','TDF, TAF and ETV are first-line high-barrier agents. Long-term follow-up includes adherence, renal/bone safety, viral suppression and HCC surveillance.']): y=1.24+i*1.22; rect(s,.8,y,.65,.65,[BLUE,TEAL,ORANGE,GREEN][i],True);textbox(s,.98,y+.17,.3,.2,str(i+1),15,WHITE,True,PP_ALIGN.CENTER);textbox(s,1.72,y+.1,10.35,.52,txt,18,DARK) footer(s) #22 references s=slide();title(s,'References and guideline framework',n=22) refs=['World Health Organization. Guidelines for the prevention, diagnosis, care and treatment for people with chronic hepatitis B infection. 2024.','Ghany MG et al. AASLD/IDSA Practice Guideline on Treatment of Chronic Hepatitis B. Hepatology. 2025 update, online publication.','European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatitis B virus infection. 2025.','Harrison’s Principles of Internal Medicine, 22nd ed. Chapter on viral hepatitis, 2025.','Goldman-Cecil Medicine. Acute and chronic hepatitis B, 26th ed.','Henry’s Clinical Diagnosis and Management by Laboratory Methods. Hepatitis B section.'] bullets(s,refs,.75,1.28,11.6,4.7,16) rect(s,.78,6.12,11.65,.56,RGBColor(252,246,226),True,ORANGE);textbox(s,1.0,6.27,11.2,.2,'Teaching content only. Verify local/national protocol, drug availability and patient-specific contraindications before treatment decisions.',13,DARK,True,PP_ALIGN.CENTER);footer(s,'Postgraduate Internal Medicine | Sources current to September 2026') # set core props prs.core_properties.title='Hepatitis B: Serology, Investigations and Management' prs.core_properties.subject='Postgraduate Internal Medicine' prs.core_properties.author='Orris' prs.save(OUT) print(OUT) PY python - <<'PY' from pptx import Presentation p='/tmp/workspace/hepatitis-b-presentation/output/Hepatitis_B_Postgraduate_iMed.pptx' prs=Presentation(p) print('slides',len(prs.slides)) print('size',__import__('os').path.getsize(p)) for n,s in enumerate(prs.slides,1): txt=' '.join(sh.text for sh in s.shapes if getattr(sh,'has_text_frame',False)) print(n, txt[:80].replace('\n',' | ')) PY

python - <<'PY' from pptx import Presentation from pptx.util import Inches, Pt from pptx.dml.color import RGBColor from pptx.enum.shapes import MSO_SHAPE, MSO_CONNECTOR from pptx.enum.text import PP_ALIGN, MSO_ANCHOR import os out='/tmp/workspace/hepatitis-b-presentation/output/Hepatitis_B_Postgraduate_iMed.pptx' prs=Presentation();prs.slide_width=Inches(13.333);prs.slide_height=Inches(7.5);blank=prs.slide_layouts[6] N=RGBColor(12,40,72); B=RGBColor(24,103,171); T=RGBColor(0,137,123); R=RGBColor(190,57,52); O=RGBColor(231,133,38); G=RGBColor(40,130,82); W=RGBColor(255,255,255); D=RGBColor(35,43,50); L=RGBColor(243,247,250); P=RGBColor(225,238,247); M=RGBColor(91,110,130) def box(s,x,y,w,h,c,rounded=False,line=None): q=s.shapes.add_shape(MSO_SHAPE.ROUNDED_RECTANGLE if rounded else MSO_SHAPE.RECTANGLE,Inches(x),Inches(y),Inches(w),Inches(h));q.fill.solid();q.fill.fore_color.rgb=c;q.line.color.rgb=line or c;return q def txt(s,x,y,w,h,z,sz=18,c=D,bold=False,align=PP_ALIGN.LEFT): q=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(h));f=q.text_frame;f.clear();f.word_wrap=True;f.margin_left=Inches(.06);f.margin_right=Inches(.05);f.margin_top=Inches(.02) for i,a in enumerate(z.split('\n')): p=f.paragraphs[0] if i==0 else f.add_paragraph();p.text=a;p.alignment=align;p.space_after=Pt(3) for r in p.runs:r.font.name='Aptos';r.font.size=Pt(sz);r.font.bold=bold;r.font.color.rgb=c return q def base(title,num): s=prs.slides.add_slide(blank);box(s,0,0,13.333,7.5,W);box(s,0,0,13.333,.18,T);txt(s,.55,.34,11.5,.45,title,27,N,True);txt(s,12.1,.4,.6,.2,str(num),11,T,True,PP_ALIGN.RIGHT);box(s,.55,7.12,12.2,.012,RGBColor(190,205,215));txt(s,.56,7.18,8,.15,'Postgraduate Internal Medicine | Hepatitis B',8,M);return s def blist(s,items,x=.8,y=1.3,w=11.7,sz=18): q=s.shapes.add_textbox(Inches(x),Inches(y),Inches(w),Inches(5.55));f=q.text_frame;f.clear();f.word_wrap=True for i,it in enumerate(items): p=f.paragraphs[0] if i==0 else f.add_paragraph();p.text=it;p.font.name='Aptos';p.font.size=Pt(sz);p.font.color.rgb=D;p.space_after=Pt(12);p.bullet=True # title s=prs.slides.add_slide(blank);box(s,0,0,13.333,7.5,N);box(s,0,0,13.333,.22,T);txt(s,.72,1.05,11,1,'Hepatitis B',42,W,True);txt(s,.74,2.25,11,.6,'Serology, investigations, management and treatment-start criteria',23,RGBColor(204,230,242));txt(s,.76,3.08,10,.4,'Postgraduate Internal Medicine teaching presentation',17,W);box(s,.74,4.0,4.55,.65,T,True);txt(s,.9,4.2,4.2,.2,'Clinical decision-making focus',14,W,True,PP_ALIGN.CENTER);txt(s,.75,6.57,11,.2,'WHO 2024 | AASLD/IDSA 2025 | EASL 2025',11,RGBColor(180,207,224)) # content s=base('Learning objectives',2);blist(s,['Interpret standard HBV serology, including the core window and isolated anti-HBc pattern.','Stage chronic HBV through virology, biochemical activity, fibrosis assessment and HCC risk.','Apply WHO 2024 treatment eligibility and recognize major guideline differences.','Select first-line therapy and plan monitoring, pregnancy, coinfection and HCC surveillance.']) s=base('HBV biology: implications for management',3);blist(s,['HBV is a DNA virus that replicates through reverse transcription. Nucleos(t)ide analogues inhibit polymerase activity.','Nuclear covalently closed circular DNA (cccDNA) persists: current drugs usually suppress viral replication rather than eradicate infection.','Liver injury is primarily immune mediated. HBV DNA indicates replication, not fibrosis severity.','Goals: prevent cirrhosis, liver failure and HCC; reduce transmission; achieve HBsAg loss where possible.']) s=base('Core HBV markers: what they mean',4) rows=[('HBsAg','Current HBV infection. Persistence >6 months = chronic infection.'),('Total anti-HBc','Prior exposure. Not generated by vaccination.'),('IgM anti-HBc','Acute/recent infection; may reappear in chronic flare/reactivation.'),('Anti-HBs','Immunity after recovery or vaccination.'),('HBeAg / anti-HBe','Replication phenotype and relative infectivity.'),('Quantitative HBV DNA','Direct replication measure: staging, treatment selection and response.')] for i,(a,b) in enumerate(rows): y=1.25+i*.82;box(s,.75,y,2.4,.62,P,True);txt(s,.88,y+.16,2.1,.2,a,14,N,True);txt(s,3.4,y+.09,8.9,.38,b,15,D) s=base('Acute HBV serology: sequence and core window',5) # Timeline for y,x,w,c,l in [(1.55,1.3,4.8,R,'HBV DNA'),(2.25,1.75,4.35,B,'HBsAg'),(2.95,2.5,2.7,O,'HBeAg'),(3.65,3.0,2.25,O,'IgM anti-HBc'),(4.35,4.1,6.15,T,'anti-HBe'),(5.05,5.05,5.45,G,'anti-HBs'),(5.75,3.15,3.25,N,'ALT')]:box(s,x,y,w,.22,c,True);txt(s,x+w+.08,y-.05,1.6,.18,l,11,c,True) box(s,4.6,1.2,1.7,4.95,RGBColor(252,246,226),True,O);txt(s,4.78,1.42,1.35,.5,'Core\nwindow',14,O,True,PP_ALIGN.CENTER);txt(s,.9,6.4,11.2,.25,'During the core window, HBsAg has disappeared and anti-HBs is not yet detectable: IgM anti-HBc establishes the diagnosis.',15,R,True) s=base('Screening serology: practical interpretation',6) heads=['HBsAg','anti-HBc','anti-HBs','Meaning'];xs=[.65,2.25,3.85,5.55];ws=[1.4,1.4,1.4,6.2] for i,h in enumerate(heads):box(s,xs[i],1.2,ws[i],.52,N,True);txt(s,xs[i],1.35,ws[i],.15,h,12,W,True,PP_ALIGN.CENTER) data=[('−','−','−','Susceptible: vaccinate'),('−','−','+','Immune after vaccination'),('−','+','+','Resolved infection: assess reactivation risk if immunosuppression'),('+','+','−','Current HBV: DNA, HBeAg, ALT and fibrosis staging'),('−','+','−','Isolated anti-HBc: window period, false positive, waned immunity or occult HBV')] for r,row in enumerate(data): y=1.82+r*.8 for i,val in enumerate(row):box(s,xs[i],y,ws[i],.67,L if r%2==0 else W,False,RGBColor(215,225,232));txt(s,xs[i]+.04,y+.15,ws[i]-.08,.3,val,13,D,i<3,PP_ALIGN.CENTER if i<3 else PP_ALIGN.LEFT) txt(s,.75,6.05,11.6,.45,'Acute HBV: HBsAg positive + IgM anti-HBc positive. Chronic HBV: HBsAg persists beyond 6 months.',16,R,True) s=base('Isolated anti-HBc: resolve the ambiguity',7);blist(s,['Repeat HBsAg, total anti-HBc and anti-HBs with a high-quality assay and review exposure history.','Check IgM anti-HBc, ALT and symptoms to exclude the acute window period.','Obtain sensitive HBV DNA if immunosuppression is planned, in HIV/HCV, dialysis, unexplained liver disease or high-risk populations.','Possible explanations: remote resolved infection with waned anti-HBs, false-positive test, occult HBV or acute window period.']) s=base('Chronic HBV phenotypes: dynamic, not “carrier” labels',8) ph=[('HBeAg-positive chronic infection','High DNA, normal ALT, little activity'),('HBeAg-positive chronic hepatitis','High DNA + raised ALT; inflammation/fibrosis'),('HBeAg-negative chronic infection','Low DNA, normal ALT'),('HBeAg-negative chronic hepatitis','Fluctuating DNA/ALT, often precore variants')] for i,(a,b) in enumerate(ph): x=.75+(i%2)*6.1;y=1.25+(i//2)*2.2;box(s,x,y,5.55,1.65,P if i%2==0 else L,True);txt(s,x+.2,y+.2,5,.28,a,16,N,True);txt(s,x+.2,y+.76,5,.38,b,15,D) txt(s,.78,6.15,11.6,.35,'Serial ALT and HBV DNA are essential because phase designation can change over time.',16,R,True) s=base('Baseline investigation of an HBsAg-positive patient',9) cols=[('Confirm / quantify',['HBsAg','HBeAg / anti-HBe','Quantitative HBV DNA','IgM anti-HBc if acute vs chronic uncertain']),('Stage liver disease',['ALT, AST, bilirubin, ALP','Albumin, INR, CBC/platelets','APRI/FIB-4, transient elastography','US liver; assess portal hypertension']),('Identify modifiers',['HIV, HCV and HDV testing','HAV immunity; alcohol/metabolic risk','Family history HCC/cirrhosis','Pregnancy and immunosuppression plans'])] for i,(h,its) in enumerate(cols): x=.58+i*4.18;box(s,x,1.35,3.78,4.85,P if i!=1 else RGBColor(234,245,241),True);txt(s,x+.2,1.66,3.3,.25,h,18,N,True,PP_ALIGN.CENTER);blist(s,its,x+.2,2.3,3.1,14) s=base('Fibrosis, cirrhosis and HCC risk assessment',10);blist(s,['Use non-invasive fibrosis tests first: transient elastography, APRI and FIB-4. ALT flares, cholestasis and congestion can falsely raise stiffness.','Assess for cirrhosis: platelets, splenomegaly, nodular liver, stiffness, synthetic dysfunction and varices. Biopsy is for discordance or decision-changing uncertainty.','WHO 2024 significant fibrosis threshold: APRI >0.5 or transient elastography >7.0 kPa. These are pragmatic treatment-access thresholds.','Cirrhosis changes management: treat with detectable HBV DNA regardless of ALT; evaluate urgently for decompensation and HCC.']);box(s,.85,5.92,5.6,.58,N,True);txt(s,1.05,6.1,5.2,.2,'APRI = [(AST / AST ULN) × 100] / platelets (10⁹/L)',14,W,True,PP_ALIGN.CENTER) s=base('WHO 2024: criteria to start treatment',11) items=[('Cirrhosis','Treat if HBV DNA detectable, irrespective of ALT.'),('Significant fibrosis','Treat if APRI >0.5 or TE >7.0 kPa.'),('Immune-active HBV','Treat if DNA >2,000 IU/mL AND ALT ≥30 U/L in men or ≥19 U/L in women.'),('Risk groups / comorbidity','Treat or strongly consider for HIV/HDV/HCV, immunosuppression, extrahepatic disease, family history HCC/cirrhosis, transmission prevention.')] for i,(a,b) in enumerate(items): y=1.22+i*1.2;box(s,.72,y,2.32,.8,[R,O,T,B][i],True);txt(s,.85,y+.18,2.05,.22,a,14,W,True,PP_ALIGN.CENTER);txt(s,3.28,y+.1,8.9,.5,b,16,D) txt(s,.75,6.22,11.5,.3,'WHO expands treatment access. Verify country programme protocol and individualize decisions.',14,R,True) s=base('Guideline comparison: how to state the answer in exams',12) heads=['Guideline','Non-cirrhotic usual pathway','Cirrhosis','Interpretation'];xs=[.55,2.45,6.7,9.05];ws=[1.8,4.1,2.2,3.7] for i,h in enumerate(heads):box(s,xs[i],1.25,ws[i],.52,N,True);txt(s,xs[i],1.39,ws[i],.16,h,12,W,True,PP_ALIGN.CENTER) rows=[('WHO 2024','DNA >2,000 + ALT ≥30 M / ≥19 F OR fibrosis threshold','Detectable DNA','Simplified access-focused'),('AASLD/IDSA 2025','HBeAg+ DNA ≥20,000 or HBeAg− ≥2,000 plus ALT/risk assessment','Treat','Shared decisions in grey zone'),('EASL 2025','Usually DNA ≥2,000 + ALT elevation and/or fibrosis','Treat','Individual risk-based')] for r,row in enumerate(rows): y=1.95+r*1.25 for i,v in enumerate(row):box(s,xs[i],y,ws[i],1.04,L if r%2==0 else W,False,RGBColor(215,225,232));txt(s,xs[i]+.06,y+.1,ws[i]-.12,.78,v,13,D,i==0) txt(s,.75,5.95,11.5,.55,'High-scoring answer: name the guideline, then integrate HBV DNA, ALT, fibrosis/cirrhosis and special-risk indications.',16,R,True) s=base('Treat irrespective of the routine ALT-DNA pattern',13) for i,(a,b) in enumerate([('Cirrhosis','Detectable HBV DNA: treat. Decompensation requires specialist care and indefinite high-barrier NA.'),('Immunosuppression','Screen HBsAg and anti-HBc before therapy. Use prophylaxis/monitoring according to serostatus and drug risk.'),('HIV coinfection','Use fully suppressive ART active against both viruses, usually tenofovir plus lamivudine or emtricitabine.'),('Pregnancy','DNA >200,000 IU/mL: late-pregnancy tenofovir plus infant immunoprophylaxis.'),('Extrahepatic disease','HBV-associated PAN or glomerular disease: antiviral treatment with specialist care.')]): y=1.15+i*.99;box(s,.7,y,2.35,.62,T if i<3 else O,True);txt(s,.83,y+.16,2.05,.18,a,13,W,True,PP_ALIGN.CENTER);txt(s,3.25,y+.05,9,.42,b,14,D) s=base('First-line therapy and selection',14) for i,(a,b) in enumerate([('TDF','High barrier to resistance. Preferred in pregnancy and HIV. Monitor renal and bone risk.'),('TAF','High barrier; better renal/bone profile than TDF. Consider availability and pregnancy evidence.'),('ETV','High barrier in nucleoside-naive people. Do not use alone in untreated HIV; renal dose adjustment.')]): y=1.4+i*1.45;box(s,.75,y,3,.9,[B,T,N][i],True);txt(s,.9,y+.3,2.7,.22,a,18,W,True,PP_ALIGN.CENTER);txt(s,4,y+.14,8.1,.52,b,16,D) txt(s,.8,5.92,11.45,.56,'Avoid lamivudine, adefovir and telbivudine as routine monotherapy. Pegylated interferon is selective finite therapy with substantial contraindications and toxicity.',15,R,True) s=base('Monitoring and duration of therapy',15);blist(s,['Before treatment: HBV DNA, ALT/AST, bilirubin, CBC, albumin/INR, eGFR ± phosphate, pregnancy status, HIV test and HCC risk.','On therapy: confirm adherence; monitor ALT and HBV DNA, drug toxicity, renal/bone parameters with TDF, and HCC risk.','Response: DNA suppression is the primary endpoint. ALT normalization supports control. HBsAg loss is uncommon but the ideal functional cure.','Do not stop therapy abruptly. Cirrhosis, HIV coinfection, ongoing high-risk immunosuppression and decompensation usually require indefinite therapy.']) s=base('Acute hepatitis B management',16);blist(s,['Most immunocompetent adults need supportive care: hydration, antiemetics, avoid alcohol/hepatotoxins and transmission counseling.','Assess severity using bilirubin, INR, glucose, renal function and mental state. Acute liver failure needs transplant-center referral.','Antivirals are generally reserved for severe, protracted or fulminant acute HBV, using a high-barrier NA.','Repeat HBsAg and anti-HBs at 6 months to establish clearance versus chronic infection.']);box(s,.8,5.85,11.5,.6,RGBColor(253,234,232),True,R);txt(s,1,6.04,11.1,.2,'Red flags: INR ≥1.5, encephalopathy, rapidly rising bilirubin, hypoglycemia, acute kidney injury or clinical deterioration.',15,R,True,PP_ALIGN.CENTER) s=base('Long-term follow-up: HCC and prevention',17);blist(s,['Ultrasound with or without AFP every 6 months for cirrhosis and other high-risk groups according to local HCC guidance. Viral suppression reduces, but does not remove, HCC risk.','In untreated chronic HBV, repeat ALT and HBV DNA at phenotype-specific intervals. One normal ALT does not prove inactive infection.','Vaccinate nonimmune household and sexual contacts. Counsel on safer sex, and do not share needles, razors or toothbrushes.','Every HBsAg-positive pregnant patient needs HBV DNA assessment and a mother-to-child transmission prevention plan.']) s=base('Case application',18);box(s,.8,1.25,11.6,1.25,P,True);txt(s,1.05,1.48,11.1,.65,'38-year-old man: HBsAg positive for 9 months; HBeAg negative; HBV DNA 18,000 IU/mL; ALT 52 U/L (ULN 40); platelets 170 × 10⁹/L; elastography 8.2 kPa.',17,N,True) blist(s,['Is this chronic HBV? Yes: HBsAg persistence >6 months.','Is there activity? Yes: DNA >2,000 IU/mL with elevated ALT.','Is fibrosis relevant? Yes: TE >7.0 kPa supports significant fibrosis in WHO 2024 framework.','Management: complete baseline evaluation, start high-barrier NA, counsel, monitor response and determine HCC surveillance need.'],.9,3.0,11.3,17) s=base('Treatment-start algorithm',19) flow=[(5,.9,3.3,.6,'HBsAg positive >6 months?',N),(5,1.85,3.3,.72,'HBV DNA + ALT + fibrosis\n+ cirrhosis + special risks',B),(.75,3.3,3.35,.8,'Cirrhosis + detectable DNA',R),(5,3.3,3.35,.8,'APRI >0.5 or TE >7 kPa',O),(9.25,3.3,3.35,.8,'DNA >2,000 + ALT threshold',T),(5,5.0,3.3,.8,'Treat: TDF, TAF or ETV\nMonitor response and HCC risk',G)] for x,y,w,h,z,c in flow:box(s,x,y,w,h,c,True);txt(s,x+.1,y+.14,w-.2,h-.16,z,14,W,True,PP_ALIGN.CENTER) txt(s,.85,6.28,11.6,.4,'Also treat or strongly consider treatment for special-risk settings: immunosuppression, coinfection, extrahepatic disease, family history and vertical-transmission prevention.',14,R,True,PP_ALIGN.CENTER) s=base('Take-home messages',20);blist(s,['Interpret HBV serology as a pattern. IgM anti-HBc is the key marker for acute infection and the core window.','Stage every chronic case with HBV DNA, ALT, fibrosis/cirrhosis assessment and HCC-risk modifiers.','WHO 2024 treatment pathways: cirrhosis, significant fibrosis, immune-active disease, and selected special-risk groups.','TDF, TAF and ETV are first-line high-barrier agents. Management is long-term and includes HCC surveillance and transmission prevention.']) s=base('References',21);blist(s,['World Health Organization. Guidelines for the prevention, diagnosis, care and treatment for people with chronic hepatitis B infection. 2024.','Ghany MG et al. AASLD/IDSA Practice Guideline on Treatment of Chronic Hepatitis B. 2025 update.','European Association for the Study of the Liver. EASL Clinical Practice Guidelines on management of HBV infection. 2025.','Harrison’s Principles of Internal Medicine, 22nd ed, 2025.','Goldman-Cecil Medicine, 26th ed. Acute and chronic hepatitis B.','Henry’s Clinical Diagnosis and Management by Laboratory Methods. Hepatitis B section.'],.75,1.25,11.7,15);box(s,.75,6.18,11.7,.54,RGBColor(252,246,226),True,O);txt(s,.95,6.34,11.3,.18,'Teaching use only: verify local protocol, drug availability and patient-specific contraindications before treatment.',13,D,True,PP_ALIGN.CENTER) prs.core_properties.title='Hepatitis B: Serology, Investigations and Management';prs.core_properties.subject='Postgraduate Internal Medicine';prs.save(out);print(out,os.path.getsize(out),len(prs.slides)) PY python - <<'PY' from pptx import Presentation import os p='/tmp/workspace/hepatitis-b-presentation/output/Hepatitis_B_Postgraduate_iMed.pptx';q=Presentation(p) print('VALID slides=',len(q.slides),'bytes=',os.path.getsize(p)) for i,s in enumerate(q.slides,1): t=' '.join(x.text for x in s.shapes if getattr(x,'has_text_frame',False));print(i,len(t),t[:55].replace('\n',' | ')) PY