A clean, professional medical treatment algorithm poster for Hepatic Encephalopathy Management based on Harrison's Principles of Internal Medicine. The poster should have: - Title at top: "HEPATIC ENCEPHALOPATHY: Treatment Algorithm" with a subtitle "Based on Harrison's Principles of Internal Medicine 22E" - A flowchart/algorithm with the following steps in order: STEP 1 (top box, red/orange): "DIAGNOSE HEPATIC ENCEPHALOPATHY - Clinical diagnosis: altered mental status + liver disease - Check for asterixis (liver flap) - Rule out alternative causes" STEP 2 (yellow box): "IDENTIFY & CORRECT PRECIPITATING FACTORS" with 5 sub-boxes in a row: "Volume Depletion → Hydrate", "GI Bleeding → Treat", "Infection/SBP → Tap ascites + Antibiotics", "Electrolyte Abnormalities → Correct", "Constipation → Catharsis" STEP 3 (green box): "ACUTE LIVER FAILURE?" with two branches - YES branch (red): "Cerebral edema risk → Hypertonic saline or Mannitol" and NO branch: Continue to Step 4 STEP 4 (blue box, main treatment): "MAINSTAY TREATMENT: LACTULOSE (Non-absorbable disaccharide) - Goal: 2-3 soft stools/day - Patient self-titrates dose - Continue long-term after first episode - Mechanism: colonic acidification → traps NH3 as NH4+" STEP 5 (purple box): "RECURRENT or REFRACTORY EPISODES? Add RIFAXIMIN 550 mg twice daily (superior to placebo when added to lactulose)" IMPORTANT NOTE box (red border): "❌ DO NOT restrict dietary protein — worsens malnutrition and sarcopenia" STEP 6 (dark blue box at bottom): "REFRACTORY HE → Refer for LIVER TRANSPLANTATION (Definitive treatment)" Use color-coded boxes, arrows connecting each step, clean medical typography, white background, professional clinical design suitable for a hospital ward.

mkdir -p /home/daytona/workspace/ascites-ppt && ls /home/daytona/workspace/ascit…

~/ascites-ppt/create_ascites_ppt.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.title = "Ascites - Harrison's Principles of Internal Medicine 22E";
pres.author = "Harrison's PMI 22E";

// ─── COLOR PALETTE ───────────────────────────────────────────────────────────
const DARK_BLUE   = "0D2B55";   // dominant navy
const MED_BLUE    = "1565C0";   // accent
const LIGHT_BLUE  = "E3F0FC";   // slide bg tint
const TEAL        = "00796B";   // subheadings
const ORANGE      = "E65100";   // warnings / highlights
const WHITE       = "FFFFFF";
const LIGHT_GRAY  = "F4F7FB";
const MEDIUM_GRAY = "90A4AE";
const DARK_TEXT   = "1A2A3A";
const ACCENT_RED  = "C62828";
const ACCENT_GOLD = "F9A825";

// ─── HELPER: Slide header band ────────────────────────────────────────────────
function addHeader(slide, title, subtitle) {
  // Dark blue top bar
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 13.3, h: 1.0,
    fill: { color: DARK_BLUE }, line: { color: DARK_BLUE }
  });
  // Accent line
  slide.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 1.0, w: 13.3, h: 0.06,
    fill: { color: ACCENT_GOLD }, line: { color: ACCENT_GOLD }
  });
  // Title
  slide.addText(title, {
    x: 0.35, y: 0.08, w: 10, h: 0.55,
    fontSize: 22, bold: true, color: WHITE, fontFace: "Calibri", margin: 0
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.35, y: 0.63, w: 10, h: 0.35,
      fontSize: 11, color: ACCENT_GOLD, fontFace: "Calibri", margin: 0, italic: true
    });
  }
  // Harrison's badge top right
  slide.addShape(pres.shapes.ROUNDED_RECTANGLE, {
    x: 11.2, y: 0.18, w: 1.85, h: 0.62,
    fill: { color: MED_BLUE }, line: { color: MED_BLUE }, rectRadius: 0.08
  });
  slide.addText("Harrison's 22E", {
    x: 11.2, y: 0.18, w: 1.85, h: 0.62,
    fontSize: 9, bold: true, color: WHITE, align: "center", valign: "middle", fontFace: "Calibri", margin: 0
  });
}

// ─── HELPER: Colored box with title + bullets ─────────────────────────────────
function addContentBox(slide, x, y, w, h, headerColor, headerText, bullets, fontSize) {
  fontSize = fontSize || 12;
  // Header bar
  slide.addShape(pres.shapes.RECTANGLE, {
    x, y, w, h: 0.42,
    fill: { color: headerColor }, line: { color: headerColor }
  });
  slide.addText(headerText, {
    x: x + 0.12, y, w: w - 0.15, h: 0.42,
    fontSize: 13, bold: true, color: WHITE, fontFace: "Calibri", valign: "middle", margin: 0
  });
  // Body
  slide.addShape(pres.shapes.RECTANGLE, {
    x, y: y + 0.42, w, h: h - 0.42,
    fill: { color: LIGHT_GRAY }, line: { color: headerColor, pt: 1.5 }
  });
  const items = bullets.map((b, i) => ({
    text: b,
    options: { bullet: true, breakLine: i < bullets.length - 1, fontSize, color: DARK_TEXT, fontFace: "Calibri" }
  }));
  slide.addText(items, {
    x: x + 0.15, y: y + 0.48, w: w - 0.3, h: h - 0.58,
    valign: "top"
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 1 — TITLE SLIDE
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  // Full background
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: DARK_BLUE }, line: { color: DARK_BLUE }
  });
  // Decorative stripe
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 3.9, w: 13.3, h: 0.09, fill: { color: ACCENT_GOLD }, line: { color: ACCENT_GOLD }
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 4.05, w: 13.3, h: 0.04, fill: { color: MED_BLUE }, line: { color: MED_BLUE }
  });

  s.addText("ASCITES", {
    x: 0.8, y: 1.2, w: 11.7, h: 1.5,
    fontSize: 72, bold: true, color: WHITE, align: "center", fontFace: "Calibri",
    charSpacing: 12
  });
  s.addText("A Comprehensive Clinical Review", {
    x: 0.8, y: 2.8, w: 11.7, h: 0.6,
    fontSize: 22, color: ACCENT_GOLD, align: "center", fontFace: "Calibri", italic: true
  });
  s.addText("Based on Harrison's Principles of Internal Medicine, 22nd Edition (2025)", {
    x: 1.5, y: 4.3, w: 10.3, h: 0.5,
    fontSize: 14, color: MEDIUM_GRAY, align: "center", fontFace: "Calibri"
  });
  s.addText("Gastroenterology & Hepatology", {
    x: 1.5, y: 4.95, w: 10.3, h: 0.4,
    fontSize: 13, color: WHITE, align: "center", fontFace: "Calibri", bold: true
  });

  // Bottom footnote
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0, y: 7.1, w: 13.3, h: 0.4, fill: { color: "0A1F3C" }, line: { color: "0A1F3C" }
  });
  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 355: Cirrhosis and Its Complications", {
    x: 0.3, y: 7.1, w: 12.7, h: 0.4,
    fontSize: 9, color: MEDIUM_GRAY, align: "center", fontFace: "Calibri"
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 2 — OVERVIEW & OUTLINE
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BLUE}, line:{color:LIGHT_BLUE}});
  addHeader(s, "Overview", "Key topics covered in this presentation");

  const topics = [
    { num: "01", title: "Definition & Pathogenesis", color: MED_BLUE },
    { num: "02", title: "Clinical Features", color: TEAL },
    { num: "03", title: "Diagnosis & SAAG", color: "6A1B9A" },
    { num: "04", title: "Treatment of Ascites", color: ORANGE },
    { num: "05", title: "Spontaneous Bacterial Peritonitis (SBP)", color: ACCENT_RED },
    { num: "06", title: "Hepatorenal Syndrome (HRS)", color: "37474F" },
    { num: "07", title: "Refractory Ascites", color: MED_BLUE },
  ];

  topics.forEach((t, i) => {
    const col = i < 4 ? 0 : 1;
    const row = i < 4 ? i : i - 4;
    const x = col === 0 ? 0.6 : 7.2;
    const y = 1.35 + row * 1.35;
    const w = col === 0 ? 6.0 : 5.8;

    s.addShape(pres.shapes.RECTANGLE, {
      x, y, w, h: 1.1,
      fill: { color: t.color }, line: { color: t.color },
      shadow: { type: "outer", color: "000000", blur: 6, offset: 2, angle: 135, opacity: 0.15 }
    });
    s.addText(t.num, {
      x: x + 0.1, y, w: 0.6, h: 1.1,
      fontSize: 28, bold: true, color: WHITE, valign: "middle", align: "center", fontFace: "Calibri", margin: 0
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x: x + 0.7, y, w: 0.04, h: 1.1, fill: { color: WHITE, transparency: 40 }, line: { color: WHITE, transparency: 40 }
    });
    s.addText(t.title, {
      x: x + 0.85, y, w: w - 0.95, h: 1.1,
      fontSize: 16, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri", margin: 0
    });
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 3 — DEFINITION & PATHOGENESIS
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BLUE}, line:{color:LIGHT_BLUE}});
  addHeader(s, "Definition & Pathogenesis", "How ascites develops in cirrhosis");

  // Definition box
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 1.25, w: 12.5, h: 0.85,
    fill: { color: DARK_BLUE }, line: { color: DARK_BLUE }
  });
  s.addText([
    { text: "DEFINITION:  ", options: { bold: true, color: ACCENT_GOLD, fontSize: 13 } },
    { text: "Ascites is the accumulation of fluid within the peritoneal cavity. The most common cause is ", options: { color: WHITE, fontSize: 13 } },
    { text: "portal hypertension related to cirrhosis", options: { bold: true, color: ACCENT_GOLD, fontSize: 13 } },
    { text: "; malignant, infectious, and cardiac causes must also be considered.", options: { color: WHITE, fontSize: 13 } }
  ], { x: 0.6, y: 1.28, w: 12.1, h: 0.79, valign: "middle", fontFace: "Calibri" });

  // Pathogenesis steps
  const steps = [
    { label: "1", title: "↑ Intrahepatic Resistance", desc: "→ Increased portal pressure", color: MED_BLUE },
    { label: "2", title: "Splanchnic Vasodilation", desc: "Nitric oxide → ↑ portal venous inflow", color: TEAL },
    { label: "3", title: "RAAS Activation", desc: "Hyperaldosteronism + sympathetic activation → Na⁺ retention", color: "6A1B9A" },
    { label: "4", title: "Fluid Accumulation", desc: "↓ Oncotic pressure (hypoalbuminemia) → peritoneal fluid", color: ORANGE },
  ];

  steps.forEach((st, i) => {
    const x = 0.4 + i * 3.15;
    s.addShape(pres.shapes.RECTANGLE, {
      x, y: 2.35, w: 3.0, h: 0.62,
      fill: { color: st.color }, line: { color: st.color }
    });
    s.addText(`${st.label}. ${st.title}`, {
      x: x + 0.1, y: 2.35, w: 2.8, h: 0.62,
      fontSize: 12, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri", margin: 0
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x, y: 2.97, w: 3.0, h: 0.85,
      fill: { color: LIGHT_GRAY }, line: { color: st.color, pt: 1.5 }
    });
    s.addText(st.desc, {
      x: x + 0.1, y: 2.97, w: 2.8, h: 0.85,
      fontSize: 11, color: DARK_TEXT, valign: "middle", fontFace: "Calibri", margin: 0
    });
    // Arrow between boxes
    if (i < 3) {
      s.addText("→", {
        x: x + 3.0, y: 2.55, w: 0.15, h: 0.45,
        fontSize: 18, bold: true, color: MED_BLUE, align: "center", valign: "middle", margin: 0
      });
    }
  });

  // Result
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 4.05, w: 12.5, h: 0.55,
    fill: { color: ACCENT_RED }, line: { color: ACCENT_RED }
  });
  s.addText("NET RESULT: Fluid constantly leaks into the peritoneal cavity; vascular filling is never achieved — the cycle continues.", {
    x: 0.55, y: 4.05, w: 12.2, h: 0.55,
    fontSize: 12, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri", margin: 0
  });

  // Grades
  s.addText("Grading of Ascites", {
    x: 0.4, y: 4.8, w: 12.5, h: 0.4,
    fontSize: 14, bold: true, color: DARK_BLUE, fontFace: "Calibri"
  });
  const grades = [
    { g: "Grade 1", d: "Detectable only by ultrasonography", c: TEAL },
    { g: "Grade 2", d: "Detectable on physical examination (shifting dullness)", c: MED_BLUE },
    { g: "Grade 3", d: "Marked abdominal distension (massive)", c: ACCENT_RED },
  ];
  grades.forEach((gr, i) => {
    const x = 0.4 + i * 4.2;
    s.addShape(pres.shapes.RECTANGLE, { x, y: 5.2, w: 4.0, h: 0.42, fill:{color: gr.c}, line:{color: gr.c}});
    s.addText(gr.g, { x: x+0.1, y: 5.2, w: 3.8, h: 0.42, fontSize: 13, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri", margin:0 });
    s.addShape(pres.shapes.RECTANGLE, { x, y: 5.62, w: 4.0, h: 0.65, fill:{color: LIGHT_GRAY}, line:{color: gr.c, pt:1.5}});
    s.addText(gr.d, { x: x+0.1, y: 5.62, w: 3.8, h: 0.65, fontSize: 11, color: DARK_TEXT, valign: "middle", fontFace: "Calibri", margin:0 });
  });

  // Footer
  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 355", {
    x: 0, y: 7.15, w: 13.3, h: 0.35, fontSize: 8, color: MEDIUM_GRAY, align: "center", fontFace: "Calibri"
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 4 — CLINICAL FEATURES & DIAGNOSIS
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BLUE}, line:{color:LIGHT_BLUE}});
  addHeader(s, "Clinical Features & Diagnosis", "Symptoms, signs, and diagnostic workup");

  // Left column - Clinical Features
  addContentBox(s, 0.35, 1.25, 5.9, 3.0, MED_BLUE, "Clinical Features", [
    "Increasing abdominal girth (often insidious)",
    "Peripheral edema accompanying fluid accumulation",
    "At least 1–2 L needed before patient notices",
    "Dyspnea if ascites is massive (diaphragm pressure)",
    "Hepatic hydrothorax — more common on the right",
    "Muscle wasting, fatigue, and weakness in massive ascites",
    "Bulging flanks on examination",
    "Fluid wave or shifting dullness on percussion",
  ], 11);

  // Right column - Diagnosis
  addContentBox(s, 6.6, 1.25, 6.35, 3.0, TEAL, "Diagnostic Workup", [
    "Physical exam: shifting dullness, fluid wave",
    "Ultrasound/CT: detect subtle amounts",
    "Diagnostic paracentesis recommended on first presentation",
    "Ascitic fluid: total protein, albumin, cell count + differential, cultures",
    "In cirrhosis: protein usually <2.5 g/dL",
    "Amylase if pancreatic ascites suspected; cytology if malignancy suspected",
    "Bedside blood culture bottles for cultures (higher yield)",
  ], 11);

  // SAAG section
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.35, y: 4.45, w: 12.6, h: 0.42,
    fill: { color: "6A1B9A" }, line: { color: "6A1B9A" }
  });
  s.addText("SERUM ASCITES-ALBUMIN GRADIENT (SAAG)", {
    x: 0.5, y: 4.45, w: 12.3, h: 0.42,
    fontSize: 14, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri", margin: 0
  });

  // SAAG formula
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.35, y: 4.87, w: 3.4, h: 0.75,
    fill: { color: WHITE }, line: { color: "6A1B9A", pt: 2 }
  });
  s.addText("SAAG = Serum Albumin − Ascitic Fluid Albumin", {
    x: 0.45, y: 4.87, w: 3.3, h: 0.75,
    fontSize: 11, bold: true, color: "6A1B9A", valign: "middle", align: "center", fontFace: "Calibri", margin: 0
  });

  const saagData = [
    { label: "SAAG ≥ 1.1 g/dL", title: "Portal Hypertension", examples: "Cirrhosis, cardiac ascites, Budd-Chiari, portal vein thrombosis", color: MED_BLUE },
    { label: "SAAG < 1.1 g/dL", title: "Non-Portal Hypertension", examples: "Malignancy, TB peritonitis, pancreatic ascites, nephrotic syndrome", color: ACCENT_RED },
  ];
  saagData.forEach((d, i) => {
    const x = 4.0 + i * 4.45;
    s.addShape(pres.shapes.RECTANGLE, { x, y: 4.87, w: 4.25, h: 0.42, fill:{color: d.color}, line:{color: d.color}});
    s.addText(`${d.label}  →  ${d.title}`, { x: x+0.1, y: 4.87, w: 4.1, h: 0.42, fontSize: 12, bold: true, color: WHITE, valign: "middle", fontFace: "Calibri", margin: 0});
    s.addShape(pres.shapes.RECTANGLE, { x, y: 5.29, w: 4.25, h: 0.33, fill:{color: LIGHT_GRAY}, line:{color: d.color, pt:1.5}});
    s.addText(`e.g. ${d.examples}`, { x: x+0.1, y: 5.29, w: 4.1, h: 0.33, fontSize: 9, color: DARK_TEXT, valign: "middle", fontFace: "Calibri", margin: 0});
  });

  s.addText("Sensitivity and specificity of SAAG ≥ 1.1 for portal hypertension: ~97%", {
    x: 0.35, y: 5.75, w: 12.6, h: 0.35,
    fontSize: 11, color: "6A1B9A", bold: true, fontFace: "Calibri"
  });

  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 355", {
    x: 0, y: 7.15, w: 13.3, h: 0.35, fontSize: 8, color: MEDIUM_GRAY, align: "center", fontFace: "Calibri"
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 5 — TREATMENT OF ASCITES
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BLUE}, line:{color:LIGHT_BLUE}});
  addHeader(s, "Treatment of Ascites", "Stepwise management based on Harrison's 22E");

  // Step 1
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:1.28, w:12.6, h:0.42, fill:{color:TEAL}, line:{color:TEAL}});
  s.addText("STEP 1: Sodium Restriction — ALL Patients", { x:0.5, y:1.28, w:12.3, h:0.42, fontSize:14, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0 });
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:1.7, w:12.6, h:0.55, fill:{color:LIGHT_GRAY}, line:{color:TEAL, pt:1.5}});
  s.addText("Restrict dietary sodium to 2 g/day (~¾ tsp salt). Avoid canned/processed foods; prefer fresh or frozen foods. Sodium pamphlets are helpful.", {
    x:0.5, y:1.7, w:12.3, h:0.55, fontSize:12, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0 });

  // Step 2 - Diuretics
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:2.42, w:12.6, h:0.42, fill:{color:MED_BLUE}, line:{color:MED_BLUE}});
  s.addText("STEP 2: Diuretic Therapy — Moderate Ascites", { x:0.5, y:2.42, w:12.3, h:0.42, fontSize:14, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0 });

  // Two drug boxes
  const drugs = [
    { name: "Spironolactone", start: "100 mg/day", max: "400 mg/day", notes: "Aldosterone antagonist — inhibits Na⁺ reabsorption in distal tubule. May cause gynecomastia (switch to amiloride 5–40 mg/d), hyperkalemia, hyponatremia", color: "6A1B9A" },
    { name: "Furosemide", start: "40 mg/day", max: "160 mg/day", notes: "Loop diuretic — used in combination with spironolactone at ratio 40:100. Add especially when peripheral edema is present", color: ORANGE },
  ];
  drugs.forEach((d, i) => {
    const x = 0.35 + i * 6.3;
    s.addShape(pres.shapes.RECTANGLE, { x, y:2.84, w:6.1, h:0.38, fill:{color:d.color}, line:{color:d.color}});
    s.addText(d.name, { x:x+0.1, y:2.84, w:5.9, h:0.38, fontSize:13, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x, y:3.22, w:6.1, h:1.05, fill:{color:LIGHT_GRAY}, line:{color:d.color, pt:1.5}});
    s.addText([
      { text: `Starting dose: ${d.start}  |  Max: ${d.max}\n`, options: { bold: true, fontSize: 11, color: DARK_TEXT } },
      { text: d.notes, options: { fontSize: 10, color: DARK_TEXT } }
    ], { x:x+0.12, y:3.22, w:5.86, h:1.05, valign:"top", fontFace:"Calibri" });
  });

  // Failure note
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:4.35, w:12.6, h:0.38, fill:{color:ACCENT_RED, transparency:15}, line:{color:ACCENT_RED}});
  s.addText("⚠  Failure of diuretics → first check dietary compliance. If compliant, escalate doses incrementally to maximum before declaring refractory.", {
    x:0.5, y:4.35, w:12.3, h:0.38, fontSize:11, color:ACCENT_RED, bold:true, valign:"middle", fontFace:"Calibri", margin:0 });

  // Drugs to avoid
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:4.85, w:12.6, h:0.38, fill:{color:"37474F"}, line:{color:"37474F"}});
  s.addText("DRUGS TO AVOID in patients with cirrhosis + ascites:", { x:0.5, y:4.85, w:6, h:0.38, fontSize:12, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:5.23, w:12.6, h:0.55, fill:{color:LIGHT_GRAY}, line:{color:"37474F", pt:1.5}});
  s.addText("NSAIDs (risk of renal failure)  |  Aminoglycosides (nephrotoxic)  |  ACE inhibitors / ARBs (use with caution — monitor BP and renal function closely)", {
    x:0.5, y:5.23, w:12.3, h:0.55, fontSize:11.5, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0 });

  // Prognosis note
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:5.9, w:12.6, h:0.45, fill:{color:DARK_BLUE}, line:{color:DARK_BLUE}});
  s.addText("Prognosis: <50% of patients survive 2 years after onset of ascites → Consider liver transplantation referral", {
    x:0.5, y:5.9, w:12.3, h:0.45, fontSize:12, color:ACCENT_GOLD, bold:true, valign:"middle", fontFace:"Calibri", margin:0});

  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 355", {
    x:0, y:7.15, w:13.3, h:0.35, fontSize:8, color:MEDIUM_GRAY, align:"center", fontFace:"Calibri" });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 6 — REFRACTORY ASCITES
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BLUE}, line:{color:LIGHT_BLUE}});
  addHeader(s, "Refractory Ascites", "Definition, pharmacologic options, and procedural management");

  // Definition
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:1.28, w:12.6, h:0.42, fill:{color:ACCENT_RED}, line:{color:ACCENT_RED}});
  s.addText("DEFINITION OF REFRACTORY ASCITES", { x:0.5, y:1.28, w:12.3, h:0.42, fontSize:14, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:1.7, w:12.6, h:0.62, fill:{color:LIGHT_GRAY}, line:{color:ACCENT_RED, pt:1.5}});
  s.addText([
    { text: "Diuretic-Resistant: ", options: { bold: true, color: ACCENT_RED } },
    { text: "Persistence of ascites despite sodium restriction + maximum diuretic doses (spiro 400 mg/d + furosemide 160 mg/d)  |  ", options: { color: DARK_TEXT } },
    { text: "Diuretic-Intractable: ", options: { bold: true, color: MED_BLUE } },
    { text: "Development of side effects that preclude maximum doses", options: { color: DARK_TEXT } },
  ], { x:0.5, y:1.7, w:12.3, h:0.62, fontSize:11.5, valign:"middle", fontFace:"Calibri" });

  // Pharmacologic additions
  s.addText("Pharmacologic Additions", { x:0.35, y:2.5, w:5.5, h:0.38, fontSize:13, bold:true, color:DARK_BLUE, fontFace:"Calibri" });
  const drugs2 = [
    { name: "Midodrine", detail: "α1-adrenergic agonist\nCounteracts splanchnic vasodilation\nImproves hemodynamics + ascites control", color: "6A1B9A" },
    { name: "Clonidine", detail: "α2-adrenergic agonist\nUsed alone or combined with midodrine\nFurther reduces sympathetic activity", color: TEAL },
    { name: "⚠ Beta-Blockers", detail: "Often used for variceal prophylaxis\nIn refractory ascites: associated with\nDECREASED SURVIVAL — use with caution", color: ACCENT_RED },
  ];
  drugs2.forEach((d, i) => {
    const x = 0.35 + i * 4.2;
    s.addShape(pres.shapes.RECTANGLE, { x, y:2.9, w:4.0, h:0.38, fill:{color:d.color}, line:{color:d.color}});
    s.addText(d.name, { x:x+0.1, y:2.9, w:3.8, h:0.38, fontSize:12, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x, y:3.28, w:4.0, h:0.85, fill:{color:LIGHT_GRAY}, line:{color:d.color, pt:1.5}});
    s.addText(d.detail, { x:x+0.1, y:3.28, w:3.8, h:0.85, fontSize:10, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
  });

  // Procedural
  s.addText("Procedural Management", { x:0.35, y:4.3, w:8, h:0.38, fontSize:13, bold:true, color:DARK_BLUE, fontFace:"Calibri" });
  const procedures = [
    { name: "Large-Volume Paracentesis (LVP)", detail: "Remove >5 L of ascitic fluid\nMust give IV 25% albumin: 6–8 g/L of ascites removed\nPrevents post-paracentesis circulatory dysfunction and death\nRepeated as needed", color: MED_BLUE },
    { name: "TIPS (Transjugular Intrahepatic Portosystemic Shunt)", detail: "Decompresses hepatic sinusoids\nSuperior to LVP for reaccumulation\nNo mortality benefit over LVP\nAssociated with ↑ hepatic encephalopathy\nConsider case-by-case", color: ORANGE },
    { name: "Liver Transplantation", detail: "Definitive treatment\nConsidered in all patients with ascites given poor prognosis (<50% survive 2 years)\nEvaluation should begin early", color: DARK_BLUE },
  ];
  procedures.forEach((p, i) => {
    const x = 0.35 + i * 4.3;
    s.addShape(pres.shapes.RECTANGLE, { x, y:4.72, w:4.1, h:0.45, fill:{color:p.color}, line:{color:p.color}});
    s.addText(p.name, { x:x+0.1, y:4.72, w:3.9, h:0.45, fontSize:10.5, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x, y:5.17, w:4.1, h:1.5, fill:{color:LIGHT_GRAY}, line:{color:p.color, pt:1.5}});
    s.addText(p.detail, { x:x+0.12, y:5.17, w:3.86, h:1.5, fontSize:10, color:DARK_TEXT, valign:"top", fontFace:"Calibri", margin:0});
  });

  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 355", {
    x:0, y:7.15, w:13.3, h:0.35, fontSize:8, color:MEDIUM_GRAY, align:"center", fontFace:"Calibri" });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 7 — SPONTANEOUS BACTERIAL PERITONITIS (SBP)
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BLUE}, line:{color:LIGHT_BLUE}});
  addHeader(s, "Spontaneous Bacterial Peritonitis (SBP)", "A common and life-threatening complication of ascites");

  // Key stats
  const stats = [
    { val: "~30%", label: "Incidence in hospitalized cirrhosis patients", color: ACCENT_RED },
    { val: "25%", label: "In-hospital mortality rate", color: ORANGE },
    { val: ">250", label: "Neutrophils/μL in ascitic fluid = diagnostic threshold", color: MED_BLUE },
  ];
  stats.forEach((st, i) => {
    const x = 0.35 + i * 4.3;
    s.addShape(pres.shapes.RECTANGLE, { x, y:1.28, w:4.1, h:0.85, fill:{color:st.color}, line:{color:st.color}});
    s.addText(st.val, { x, y:1.28, w:4.1, h:0.5, fontSize:26, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", margin:0});
    s.addText(st.label, { x:x+0.1, y:1.73, w:3.9, h:0.4, fontSize:9.5, color:WHITE, align:"center", fontFace:"Calibri", margin:0});
  });

  // Left - Pathogenesis + Organisms
  addContentBox(s, 0.35, 2.35, 6.0, 2.6, "37474F", "Pathogenesis & Organisms", [
    "Mechanism: bacterial translocation — gut flora traverse intestine into mesenteric lymph nodes → bacteremia → seeding of ascitic fluid",
    "Most common: Escherichia coli and other gram-negative gut bacteria",
    "Gram-positive: Streptococcus viridans, Staphylococcus aureus, Enterococcus spp.",
    "If >2 organisms identified → suspect secondary peritonitis (perforated viscus)",
  ], 11);

  // Right - Clinical Features
  addContentBox(s, 6.7, 2.35, 6.25, 2.6, TEAL, "Clinical Presentation (may be subtle!)", [
    "Fever",
    "Abdominal pain or discomfort",
    "Altered mental status",
    "Elevated WBC count",
    "Acute kidney injury",
    "⚠ May present without ANY of these features → High clinical suspicion required",
    "Peritoneal tap recommended in all cirrhosis patients hospitalized with ascites",
  ], 11);

  // Treatment
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:5.1, w:12.6, h:0.42, fill:{color:MED_BLUE}, line:{color:MED_BLUE}});
  s.addText("TREATMENT", { x:0.5, y:5.1, w:12.3, h:0.42, fontSize:14, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});

  const txts = [
    { t: "Antibiotic", d: "IV 3rd-generation cephalosporin × 5 days\n(Cefotaxime / Ceftriaxone)" , c: MED_BLUE},
    { t: "Albumin (mandatory)", d: "IV Albumin:\n  Day 1: 1.5 g/kg body weight\n  Day 3: 1.0 g/kg body weight\nReduces renal failure & improves survival", c: TEAL},
    { t: "Prophylaxis", d: "GI bleeding: SBP prophylaxis at presentation\nPost-SBP: Quinolone antibiotic long-term to prevent recurrence", c: "6A1B9A"},
  ];
  txts.forEach((t, i) => {
    const x = 0.35 + i * 4.3;
    s.addShape(pres.shapes.RECTANGLE, { x, y:5.52, w:4.1, h:0.38, fill:{color:t.c}, line:{color:t.c}});
    s.addText(t.t, { x:x+0.1, y:5.52, w:3.9, h:0.38, fontSize:11, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x, y:5.9, w:4.1, h:1.0, fill:{color:LIGHT_GRAY}, line:{color:t.c, pt:1.5}});
    s.addText(t.d, { x:x+0.1, y:5.9, w:3.9, h:1.0, fontSize:10, color:DARK_TEXT, valign:"top", fontFace:"Calibri", margin:0});
  });

  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 355", {
    x:0, y:7.15, w:13.3, h:0.35, fontSize:8, color:MEDIUM_GRAY, align:"center", fontFace:"Calibri" });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 8 — HEPATORENAL SYNDROME
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BLUE}, line:{color:LIGHT_BLUE}});
  addHeader(s, "Hepatorenal Syndrome (HRS)", "Functional renal failure in advanced cirrhosis");

  // Definition box
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:1.28, w:12.6, h:0.75, fill:{color:DARK_BLUE}, line:{color:DARK_BLUE}});
  s.addText("Functional renal failure without renal pathology; occurs in ~10% of patients with advanced cirrhosis or acute liver failure. Marked renal vasoconstriction + reduced systemic vascular resistance.", {
    x:0.5, y:1.28, w:12.3, h:0.75, fontSize:12, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});

  // Types
  s.addText("Classification", { x:0.35, y:2.18, w:5, h:0.38, fontSize:13, bold:true, color:DARK_BLUE, fontFace:"Calibri"});
  const types = [
    { type: "HRS-AKI (Type 1 HRS)", def: "Rapid progressive renal impairment\n• Creatinine rise ≥0.3 mg/dL in 48h, OR ≥50% from baseline\n• Poor prognosis", color: ACCENT_RED },
    { type: "HRS-CKD (Type 2 HRS)", def: "Stable reduction in GFR\n• Persistent ↑ creatinine\n• Associated with refractory ascites\n• Relatively better outcome than Type 1", color: ORANGE },
  ];
  types.forEach((t, i) => {
    const x = 0.35 + i * 6.3;
    s.addShape(pres.shapes.RECTANGLE, { x, y:2.58, w:6.1, h:0.42, fill:{color:t.color}, line:{color:t.color}});
    s.addText(t.type, { x:x+0.1, y:2.58, w:5.9, h:0.42, fontSize:12, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x, y:3.0, w:6.1, h:0.92, fill:{color:LIGHT_GRAY}, line:{color:t.color, pt:1.5}});
    s.addText(t.def, { x:x+0.12, y:3.0, w:5.86, h:0.92, fontSize:11, color:DARK_TEXT, valign:"top", fontFace:"Calibri", margin:0});
  });

  // Diagnosis
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:4.1, w:12.6, h:0.42, fill:{color:TEAL}, line:{color:TEAL}});
  s.addText("Diagnosis — Exclusion Required (HRS-AKI)", { x:0.5, y:4.1, w:12.3, h:0.42, fontSize:14, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:4.52, w:12.6, h:0.65, fill:{color:LIGHT_GRAY}, line:{color:TEAL, pt:1.5}});
  s.addText("1. Stop diuretics  |  2. Infuse albumin 1 g/kg/day × 48 hrs without improvement  |  3. Exclude intrinsic kidney disease (ATN, AIN, GN) and obstructive uropathy", {
    x:0.5, y:4.52, w:12.3, h:0.65, fontSize:11.5, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});

  // Treatment
  s.addShape(pres.shapes.RECTANGLE, { x:0.35, y:5.32, w:12.6, h:0.42, fill:{color:MED_BLUE}, line:{color:MED_BLUE}});
  s.addText("TREATMENT — in order of preference", { x:0.5, y:5.32, w:12.3, h:0.42, fontSize:14, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
  const hrsTx = [
    { line: "1st Line: Vasoconstrictors", detail: "Terlipressin (preferred) or Norepinephrine (requires ICU monitoring)", c: ACCENT_RED },
    { line: "2nd Line: Midodrine + Octreotide + IV Albumin", detail: "Used in the US (terlipressin availability limited); now considered 3rd line per Harrison's 22E", c: ORANGE },
    { line: "Dialysis / RRT", detail: "If vasoconstrictors fail; bridge to transplant", c: "37474F" },
    { line: "Liver Transplantation", detail: "BEST therapy — recovery of renal function typical", c: DARK_BLUE },
  ];
  hrsTx.forEach((t, i) => {
    const x = 0.35 + i * 3.15;
    s.addShape(pres.shapes.RECTANGLE, { x, y:5.74, w:3.0, h:0.38, fill:{color:t.c}, line:{color:t.c}});
    s.addText(t.line, { x:x+0.08, y:5.74, w:2.84, h:0.38, fontSize:9, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x, y:6.12, w:3.0, h:0.7, fill:{color:LIGHT_GRAY}, line:{color:t.c, pt:1.5}});
    s.addText(t.detail, { x:x+0.08, y:6.12, w:2.84, h:0.7, fontSize:9, color:DARK_TEXT, valign:"top", fontFace:"Calibri", margin:0});
  });

  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 355", {
    x:0, y:7.15, w:13.3, h:0.35, fontSize:8, color:MEDIUM_GRAY, align:"center", fontFace:"Calibri" });
}

// ─────────────────────────────────────────────────────────────────────────────
// SLIDE 9 — SUMMARY & KEY TAKE-AWAYS
// ─────────────────────────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:DARK_BLUE}, line:{color:DARK_BLUE}});
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:1.08, w:13.3, h:0.06, fill:{color:ACCENT_GOLD}, line:{color:ACCENT_GOLD}});
  s.addShape(pres.shapes.RECTANGLE, { x:0, y:6.8, w:13.3, h:0.06, fill:{color:ACCENT_GOLD}, line:{color:ACCENT_GOLD}});

  s.addText("KEY TAKE-AWAYS", {
    x:0.5, y:0.22, w:12.3, h:0.78, fontSize:30, bold:true, color:WHITE, align:"center", fontFace:"Calibri", charSpacing:6
  });

  const points = [
    { icon: "1", text: "Cirrhosis + portal hypertension accounts for >80% of ascites — always consider SAAG to differentiate", color: MED_BLUE },
    { icon: "2", text: "SAAG ≥ 1.1 g/dL → portal hypertension; SAAG < 1.1 → non-portal cause (malignancy, TB, nephrotic syndrome)", color: TEAL },
    { icon: "3", text: "Treatment: Sodium restriction (2 g/day) → Spironolactone + Furosemide (ratio 100:40) → Escalate to max → LVP / TIPS for refractory cases", color: "6A1B9A" },
    { icon: "4", text: "Always give IV albumin 6–8 g/L after LVP of ≥5 L to prevent post-paracentesis circulatory dysfunction", color: ORANGE },
    { icon: "5", text: "SBP: diagnose if ascitic neutrophils >250/µL → Treat with IV 3rd-gen cephalosporin + albumin (1.5 g/kg day 1, 1.0 g/kg day 3)", color: ACCENT_RED },
    { icon: "6", text: "HRS: best treated with liver transplantation. Use terlipressin/norepinephrine as vasoconstrictors; avoid NSAIDs, aminoglycosides, ACE inhibitors", color: "00838F" },
    { icon: "7", text: "Prognosis is poor (<50% survive 2 years) — refer all eligible patients for liver transplant evaluation early", color: ACCENT_GOLD },
  ];

  points.forEach((p, i) => {
    const col = i < 4 ? 0 : 1;
    const row = i < 4 ? i : i - 4;
    const x = col === 0 ? 0.4 : 6.85;
    const y = 1.28 + row * 1.3;
    const w = col === 0 ? 6.2 : 6.1;

    s.addShape(pres.shapes.RECTANGLE, { x, y, w:0.55, h:1.1, fill:{color:p.color}, line:{color:p.color}});
    s.addText(p.icon, { x, y, w:0.55, h:1.1, fontSize:22, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:x+0.55, y, w:w-0.55, h:1.1, fill:{color:"0A1F3C"}, line:{color:p.color, pt:1}});
    s.addText(p.text, { x:x+0.68, y, w:w-0.75, h:1.1, fontSize:11, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
  });

  // Bottom reference
  s.addText("Source: Harrison's Principles of Internal Medicine, 22nd Edition (2025)  |  Chapters 39 & 355", {
    x:0, y:6.88, w:13.3, h:0.6, fontSize:10, color:MEDIUM_GRAY, align:"center", valign:"middle", fontFace:"Calibri"
  });
}

// ─────────────────────────────────────────────────────────────────────────────
// WRITE FILE
// ─────────────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/ascites-ppt/Ascites_Harrisons_22E.pptx" })
  .then(() => console.log("SUCCESS: /home/daytona/workspace/ascites-ppt/Ascites_Harrisons_22E.pptx"))
  .catch(err => { console.error("ERROR:", err); process.exit(1); });

cd /home/daytona/workspace/ascites-ppt && node create_ascites_ppt.js

"cdn.orris.care" in /textbooks/9781265977061

node /home/daytona/skills/shared/scripts/fetch_images.js \ "https://cdn.orris.…

node /home/daytona/skills/shared/scripts/fetch_images.js \ "https://cdn.orris.…

~/ascites-ppt/create_ra_ppt.js

const pptxgen = require("pptxgenjs");
const fs = require("fs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.title = "Rheumatoid Arthritis - Harrison's PMI 22E";

// ─── PALETTE ──────────────────────────────────────────────────────────────────
const DARK        = "1A1A2E";   // deep navy-black
const NAVY        = "16213E";   // slide backgrounds (dark slides)
const TEAL        = "0F3460";   // section headers
const ACCENT      = "E94560";   // hot coral accent
const GOLD        = "F5A623";   // highlight / warning
const TEAL_LIGHT  = "00B4D8";   // info boxes
const GREEN       = "00897B";   // positive / treatment
const PURPLE      = "7B2D8B";   // autoantibodies
const ORANGE      = "E65100";   // warnings
const WHITE       = "FFFFFF";
const LIGHT_BG    = "F0F4F8";
const CARD_BG     = "FFFFFF";
const DARK_TEXT   = "1A2A3A";
const GRAY        = "90A4AE";
const LIGHT_TEAL  = "E0F7FA";

// ─── Image data ───────────────────────────────────────────────────────────────
const img0 = fs.readFileSync("/tmp/ra_img0.b64", "utf8"); // global prevalence map

// ─── HELPERS ──────────────────────────────────────────────────────────────────
function hdr(s, title, sub) {
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:0.95, fill:{color:TEAL}, line:{color:TEAL}});
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0.95,w:13.3,h:0.06, fill:{color:ACCENT}, line:{color:ACCENT}});
  s.addText(title, { x:0.35,y:0.08,w:10,h:0.52, fontSize:22, bold:true, color:WHITE, fontFace:"Calibri", margin:0});
  if(sub) s.addText(sub, { x:0.35,y:0.6,w:10,h:0.3, fontSize:11, color:GOLD, fontFace:"Calibri", italic:true, margin:0});
  s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:11.2,y:0.18,w:1.85,h:0.6, fill:{color:ACCENT}, line:{color:ACCENT}, rectRadius:0.08});
  s.addText("Harrison's 22E", { x:11.2,y:0.18,w:1.85,h:0.6, fontSize:9, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", margin:0});
}
function foot(s) {
  s.addText("Harrison's Principles of Internal Medicine 22E  |  Chapter 370: Rheumatoid Arthritis", {
    x:0,y:7.17,w:13.3,h:0.33, fontSize:8, color:GRAY, align:"center", fontFace:"Calibri"});
}
function box(s, x, y, w, h, hColor, title, lines, fs_) {
  fs_ = fs_||11;
  s.addShape(pres.shapes.RECTANGLE, { x,y,w,h:0.4, fill:{color:hColor}, line:{color:hColor}});
  s.addText(title, { x:x+0.1,y,w:w-0.15,h:0.4, fontSize:13, bold:true, color:WHITE, fontFace:"Calibri", valign:"middle", margin:0});
  s.addShape(pres.shapes.RECTANGLE, { x,y:y+0.4,w,h:h-0.4, fill:{color:LIGHT_BG}, line:{color:hColor, pt:1.5}});
  const items = lines.map((b,i)=>({ text:b, options:{ bullet:true, breakLine:i<lines.length-1, fontSize:fs_, color:DARK_TEXT, fontFace:"Calibri"}}));
  s.addText(items, { x:x+0.14,y:y+0.46,w:w-0.28,h:h-0.56, valign:"top"});
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  // Dark gradient background via shapes
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:NAVY}, line:{color:NAVY}});
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:5.5,h:7.5, fill:{color:TEAL}, line:{color:TEAL}});
  s.addShape(pres.shapes.RECTANGLE, { x:5.5,y:0,w:0.06,h:7.5, fill:{color:ACCENT}, line:{color:ACCENT}});

  // Title text on dark right side
  s.addText("RHEUMATOID", { x:5.8,y:1.0,w:7.2,h:1.0, fontSize:52, bold:true, color:WHITE, fontFace:"Calibri", charSpacing:4});
  s.addText("ARTHRITIS", { x:5.8,y:1.95,w:7.2,h:1.0, fontSize:52, bold:true, color:ACCENT, fontFace:"Calibri", charSpacing:4});
  s.addShape(pres.shapes.RECTANGLE, { x:5.8,y:3.05,w:7.1,h:0.05, fill:{color:GOLD}, line:{color:GOLD}});
  s.addText("A Comprehensive Clinical Review", { x:5.8,y:3.2,w:7.1,h:0.45, fontSize:18, color:GOLD, fontFace:"Calibri", italic:true});
  s.addText("Based on Harrison's Principles of Internal Medicine\n22nd Edition (2025)", {
    x:5.8,y:3.85,w:7.1,h:0.8, fontSize:13, color:GRAY, fontFace:"Calibri"});

  // Left-side topic pills
  const topics = ["Epidemiology","Pathogenesis","Clinical Features","Diagnosis & Criteria","DMARDs & Biologics","Treatment Algorithm","Extra-articular Features","Prognosis"];
  topics.forEach((t,i)=>{
    s.addShape(pres.shapes.ROUNDED_RECTANGLE, { x:0.2,y:0.3+i*0.88,w:5.1,h:0.7, fill:{color:"0A2240", transparency:0}, line:{color:TEAL_LIGHT, pt:1}, rectRadius:0.06});
    s.addText(`${String(i+1).padStart(2,'0')}  ${t}`, { x:0.35,y:0.3+i*0.88,w:4.9,h:0.7, fontSize:13, color:WHITE, fontFace:"Calibri", valign:"middle", margin:0});
  });

  s.addText("Chapter 370  |  Rheumatology  |  Internal Medicine", { x:5.8,y:7.0,w:7.2,h:0.4, fontSize:9, color:GRAY, fontFace:"Calibri"});
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — EPIDEMIOLOGY & RISK FACTORS (with prevalence map image)
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BG}, line:{color:LIGHT_BG}});
  hdr(s,"Epidemiology & Risk Factors","Global burden, genetics, and environmental triggers");

  // Stats row
  const stats = [
    { v:"0.5–1%",  l:"Global prevalence", c:TEAL },
    { v:"3:1",     l:"Female-to-Male ratio", c:ACCENT },
    { v:"40-60y",  l:"Peak onset age", c:GREEN },
    { v:"~60%",    l:"Risk attributed to genetics", c:PURPLE },
    { v:"1.5–3.5×",l:"Smoking risk increase", c:ORANGE },
  ];
  stats.forEach((st,i)=>{
    const x = 0.3+i*2.54;
    s.addShape(pres.shapes.RECTANGLE, { x,y:1.22,w:2.4,h:0.65, fill:{color:st.c}, line:{color:st.c}});
    s.addText(st.v, { x,y:1.22,w:2.4,h:0.42, fontSize:20, bold:true, color:WHITE, align:"center", fontFace:"Calibri", margin:0});
    s.addText(st.l, { x:x+0.05,y:1.59,w:2.3,h:0.28, fontSize:8.5, color:WHITE, align:"center", fontFace:"Calibri", margin:0});
  });

  // Left content boxes
  box(s, 0.3, 2.07, 5.9, 2.3, TEAL, "Genetic Risk Factors",[
    "HLA-DRB1 shared epitope (SE) — major risk allele",
    "*0401/*0404 in Northern Europeans (50–70%); *0405/*0901 in Asians",
    "Pima/Tlingit Native Americans: prevalence up to 7% (*1042 allele)",
    "PTPN22 gene — regulates T/B cell function; absent in East Asians",
    "PADI4 gene — encodes enzyme converting arginine → citrulline",
    ">100 non-MHC loci identified by GWAS; individually modest effect",
  ],10.5);

  box(s, 0.3, 4.52, 5.9, 2.5, ORANGE, "Environmental Risk Factors",[
    "Cigarette smoking: RR 1.5–3.5×; synergizes with SE alleles → 20–40× risk",
    "Risk persists 15 years after smoking cessation",
    "Almost exclusively ACPA/RF-positive disease",
    "Silica inhalation and inhalant occupations",
    "Periodontal disease / Porphyromonas gingivalis (PAD enzyme → citrullination)",
    "Gut and oral microbiome dysbiosis — emerging evidence",
  ],10.5);

  // Right: Prevalence map image
  s.addShape(pres.shapes.RECTANGLE, { x:6.45,y:2.07,w:6.6,h:4.3, fill:{color:WHITE}, line:{color:TEAL, pt:1.5}});
  s.addText("FIGURE 370-1  Global Prevalence & Genetic Associations of RA", { x:6.55,y:2.1,w:6.4,h:0.38, fontSize:10, bold:true, color:TEAL, fontFace:"Calibri", margin:0});
  s.addImage({ data: img0, x:6.5,y:2.52,w:6.5,h:3.6 });
  s.addText("HLA-DRB1 mutations are found globally; specific alleles vary by ethnicity. (Harrison's 22E)", { x:6.5,y:6.17,w:6.5,h:0.3, fontSize:8, color:GRAY, fontFace:"Calibri", italic:true });

  foot(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — PATHOGENESIS
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BG}, line:{color:LIGHT_BG}});
  hdr(s,"Pathogenesis","Autoimmune cascade driving synovial inflammation and joint destruction");

  // Cascade flow
  const steps = [
    { n:"1", t:"Genetic + Environmental Trigger", d:"SE alleles + smoking → citrullination of self-proteins (ACPA generation)", c:TEAL },
    { n:"2", t:"Autoantibody Production", d:"RF + ACPA produced years before clinical disease. Immune complex deposition in synovium", c:PURPLE },
    { n:"3", t:"Synovial T-cell Activation", d:"CD4+ T cells, B cells infiltrate synovium. Th1/Th17 polarization → cytokine release", c:ACCENT },
    { n:"4", t:"Cytokine Storm", d:"TNF-α, IL-1, IL-6, IL-17 drive pannus formation. Synoviocyte (FLS) proliferation", c:ORANGE },
    { n:"5", t:"Pannus & Joint Destruction", d:"Aggressive granulation tissue (pannus) erodes cartilage and bone. RANKL activates osteoclasts", c:ACCENT },
  ];
  steps.forEach((st,i)=>{
    const x = 0.25 + i*2.58;
    s.addShape(pres.shapes.RECTANGLE, { x,y:1.22,w:0.6,h:3.2, fill:{color:st.c}, line:{color:st.c}});
    s.addText(st.n, { x,y:1.22,w:0.6,h:0.6, fontSize:20, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:x+0.6,y:1.22,w:1.88,h:0.62, fill:{color:st.c}, line:{color:st.c}});
    s.addText(st.t, { x:x+0.65,y:1.22,w:1.78,h:0.62, fontSize:11, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:x+0.6,y:1.84,w:1.88,h:2.58, fill:{color:WHITE}, line:{color:st.c, pt:1.5}});
    s.addText(st.d, { x:x+0.7,y:1.9,w:1.68,h:2.4, fontSize:10, color:DARK_TEXT, valign:"top", fontFace:"Calibri", margin:0});
    if(i<4) s.addText("→", { x:x+2.49,y:2.5,w:0.2,h:0.5, fontSize:20, bold:true, color:st.c, align:"center", valign:"middle", margin:0});
  });

  // Key mediators
  s.addShape(pres.shapes.RECTANGLE, { x:0.25,y:4.62,w:12.8,h:0.42, fill:{color:NAVY}, line:{color:NAVY}});
  s.addText("KEY THERAPEUTIC TARGETS in the Pathogenesis Cascade:", { x:0.4,y:4.62,w:12.5,h:0.42, fontSize:12, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});

  const tgts = [
    { label:"TNF-α", rx:"Etanercept, Infliximab, Adalimumab, Certolizumab, Golimumab", c:ACCENT },
    { label:"IL-6R", rx:"Tocilizumab, Sarilumab", c:TEAL },
    { label:"CD80/86 (T-cell co-stim)", rx:"Abatacept", c:PURPLE },
    { label:"CD20 (B cells)", rx:"Rituximab", c:GREEN },
    { label:"JAK1/2/3", rx:"Tofacitinib, Baricitinib, Upadacitinib", c:ORANGE },
  ];
  tgts.forEach((t,i)=>{
    const x = 0.25 + i*2.58;
    s.addShape(pres.shapes.RECTANGLE, { x,y:5.04,w:2.45,h:0.42, fill:{color:t.c}, line:{color:t.c}});
    s.addText(t.label, { x:x+0.06,y:5.04,w:2.35,h:0.42, fontSize:11, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x,y:5.46,w:2.45,h:0.85, fill:{color:LIGHT_BG}, line:{color:t.c, pt:1.5}});
    s.addText(t.rx, { x:x+0.07,y:5.46,w:2.31,h:0.85, fontSize:9, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
  });

  foot(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — CLINICAL FEATURES
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BG}, line:{color:LIGHT_BG}});
  hdr(s,"Clinical Features","Articular and extra-articular manifestations");

  // Articular features
  box(s, 0.3,1.2, 4.1, 3.35, TEAL, "Articular Features",[
    "Symmetric polyarthritis — hallmark",
    "Small joints of hands/wrists/feet first affected",
    "Morning stiffness >1 hour (disease activity marker)",
    "MCP, PIP joints involved (NOT DIP)",
    "Pain, swelling, warmth, tenderness on palpation",
    "Soft tissue swelling vs bony enlargement (OA)",
    "Pannus erosion → deformity over time",
    "Boutonniere deformity, Swan-neck deformity",
    "Ulnar deviation of fingers",
    "Z-deformity of thumb",
  ],10.5);

  // Joint deformities illustration box
  s.addShape(pres.shapes.RECTANGLE, { x:4.55,y:1.2,w:3.6,h:3.35, fill:{color:WHITE}, line:{color:TEAL, pt:1.5}});
  s.addText("Joint Deformities in RA", { x:4.65,y:1.25,w:3.4,h:0.4, fontSize:12, bold:true, color:TEAL, fontFace:"Calibri", margin:0});
  const deforms = [
    { d:"Boutonnière", m:"PIP flexion + DIP hyperextension" },
    { d:"Swan-neck", m:"PIP hyperextension + DIP flexion" },
    { d:"Ulnar deviation", m:"MCP joint drift toward ulna" },
    { d:"Z-thumb", m:"MCP flexion + IP hyperextension" },
    { d:"Piano-key sign", m:"Subluxation of distal ulna" },
    { d:"Atlanto-axial subluxation", m:"Cervical spine — neurological emergency" },
  ];
  deforms.forEach((d,i)=>{
    s.addShape(pres.shapes.RECTANGLE, { x:4.65,y:1.7+i*0.4,w:1.3,h:0.36, fill:{color:TEAL, transparency:i%2===0?0:30}, line:{color:TEAL}});
    s.addText(d.d, { x:4.67,y:1.7+i*0.4,w:1.27,h:0.36, fontSize:9, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:5.95,y:1.7+i*0.4,w:2.1,h:0.36, fill:{color:LIGHT_BG}, line:{color:TEAL, pt:0.8}});
    s.addText(d.m, { x:6.0,y:1.7+i*0.4,w:2.0,h:0.36, fontSize:9, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
  });

  // Extra-articular features
  s.addShape(pres.shapes.RECTANGLE, { x:8.3,y:1.2,w:4.7,h:3.35, fill:{color:WHITE}, line:{color:ACCENT, pt:1.5}});
  s.addShape(pres.shapes.RECTANGLE, { x:8.3,y:1.2,w:4.7,h:0.4, fill:{color:ACCENT}, line:{color:ACCENT}});
  s.addText("Extra-articular Features", { x:8.4,y:1.2,w:4.5,h:0.4, fontSize:13, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
  const eaf = [
    { sys:"Skin", feat:"Rheumatoid nodules (20–30%), vasculitis" },
    { sys:"Pulmonary", feat:"ILD (UIP/NSIP), pleuritis, nodules, Caplan syndrome" },
    { sys:"Cardiac", feat:"Pericarditis, myocarditis, ↑ CVD risk" },
    { sys:"Eye", feat:"Keratoconjunctivitis sicca, scleritis, episcleritis" },
    { sys:"Haematologic", feat:"Felty syndrome (RA + neutropenia + splenomegaly)" },
    { sys:"Neurologic", feat:"Mononeuritis multiplex, cervical myelopathy" },
    { sys:"Renal", feat:"Amyloidosis (secondary), drug-related" },
    { sys:"Systemic", feat:"Fatigue, weight loss, low-grade fever" },
  ];
  eaf.forEach((e,i)=>{
    s.addShape(pres.shapes.RECTANGLE, { x:8.35,y:1.65+i*0.34,w:1.05,h:0.3, fill:{color:ACCENT, transparency:i%2===0?0:25}, line:{color:ACCENT}});
    s.addText(e.sys, { x:8.37,y:1.65+i*0.34,w:1.0,h:0.3, fontSize:8.5, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:9.4,y:1.65+i*0.34,w:3.5,h:0.3, fill:{color:LIGHT_BG}, line:{color:ACCENT, pt:0.8}});
    s.addText(e.feat, { x:9.45,y:1.65+i*0.34,w:3.4,h:0.3, fontSize:8.5, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
  });

  // Disease activity & labs
  s.addShape(pres.shapes.RECTANGLE, { x:0.3,y:4.7,w:12.7,h:0.4, fill:{color:NAVY}, line:{color:NAVY}});
  s.addText("Laboratory Findings & Autoantibodies", { x:0.45,y:4.7,w:12.4,h:0.4, fontSize:13, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
  const labs = [
    { l:"RF (Rheumatoid Factor)", d:"IgM anti-IgG. Positive in ~75–80%. NOT specific — also in SLE, Sjögren's, infections, healthy elderly", c:PURPLE },
    { l:"Anti-CCP (ACPA)", d:"Highly specific (~95%) and sensitive (~70%). Predictive of erosive disease. Present years before symptoms", c:TEAL },
    { l:"ESR / CRP", d:"Elevated in active disease. Useful to monitor response to treatment. CRP also predicts CV risk", c:GREEN },
    { l:"ANA", d:"Positive in ~30% of RA patients. Low titer. Does not indicate SLE", c:ORANGE },
  ];
  labs.forEach((l,i)=>{
    const x=0.3+i*3.17;
    s.addShape(pres.shapes.RECTANGLE, { x,y:5.1,w:3.05,h:0.38, fill:{color:l.c}, line:{color:l.c}});
    s.addText(l.l, { x:x+0.08,y:5.1,w:2.89,h:0.38, fontSize:10, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x,y:5.48,w:3.05,h:1.35, fill:{color:LIGHT_BG}, line:{color:l.c, pt:1.5}});
    s.addText(l.d, { x:x+0.09,y:5.53,w:2.87,h:1.25, fontSize:9.5, color:DARK_TEXT, valign:"top", fontFace:"Calibri", margin:0});
  });

  foot(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — 2010 ACR/EULAR CLASSIFICATION CRITERIA
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BG}, line:{color:LIGHT_BG}});
  hdr(s,"2010 ACR/EULAR Classification Criteria for RA","Score ≥6/10 = definite RA (requires at least 1 joint with synovitis not explained by another diagnosis)");

  // Score table
  s.addShape(pres.shapes.RECTANGLE, { x:0.3,y:1.22,w:12.7,h:0.45, fill:{color:TEAL}, line:{color:TEAL}});
  const cols = ["DOMAIN","FINDING","SCORE"];
  const cx = [0.35, 3.2, 12.35];
  const cw = [2.8, 8.95, 0.6];
  cols.forEach((c,i)=> s.addText(c, { x:cx[i],y:1.22,w:cw[i],h:0.45, fontSize:12, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0, align: i===2?"center":"left"}));

  const criteria = [
    { dom:"Joint Involvement", find:"1 large joint (shoulder, elbow, hip, knee, ankle)", score:"0" },
    { dom:"", find:"2–10 large joints", score:"1" },
    { dom:"", find:"1–3 small joints (MCP, PIP, wrist, 2nd–5th MTP)", score:"2" },
    { dom:"", find:"4–10 small joints", score:"3" },
    { dom:"", find:">10 joints (at least 1 small joint)", score:"5" },
    { dom:"Serology", find:"Negative RF AND negative ACPA", score:"0" },
    { dom:"", find:"Low-positive RF OR low-positive ACPA (≤3× ULN)", score:"2" },
    { dom:"", find:"High-positive RF OR high-positive ACPA (>3× ULN)", score:"3" },
    { dom:"Acute-Phase Reactants", find:"Normal CRP AND normal ESR", score:"0" },
    { dom:"", find:"Abnormal CRP OR abnormal ESR", score:"1" },
    { dom:"Duration of Symptoms", find:"<6 weeks", score:"0" },
    { dom:"", find:"≥6 weeks", score:"1" },
  ];
  const rowColors = [TEAL,TEAL,"","","",PURPLE,PURPLE,PURPLE,GREEN,GREEN,ORANGE,ORANGE];
  criteria.forEach((r,i)=>{
    const y = 1.67 + i*0.42;
    const bg = i%2===0 ? WHITE : LIGHT_BG;
    s.addShape(pres.shapes.RECTANGLE, { x:0.3,y,w:12.7,h:0.42, fill:{color:bg}, line:{color:"D0D8E0", pt:0.5}});
    if(r.dom) {
      s.addShape(pres.shapes.RECTANGLE, { x:0.3,y,w:2.85,h:0.42, fill:{color:rowColors[i]||TEAL}, line:{color:rowColors[i]||TEAL}});
      s.addText(r.dom, { x:0.38,y,w:2.7,h:0.42, fontSize:10, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    }
    s.addText(r.find, { x:3.25,y,w:8.8,h:0.42, fontSize:10, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:12.25,y,w:0.75,h:0.42, fill:{color:Number(r.score)>=3?ACCENT:Number(r.score)>=1?GOLD:LIGHT_BG}, line:{color:"D0D8E0"}});
    s.addText(r.score, { x:12.25,y,w:0.75,h:0.42, fontSize:12, bold:true, color:Number(r.score)>=1?WHITE:DARK_TEXT, align:"center", valign:"middle", fontFace:"Calibri", margin:0});
  });

  s.addShape(pres.shapes.RECTANGLE, { x:0.3,y:6.7,w:12.7,h:0.42, fill:{color:ACCENT}, line:{color:ACCENT}});
  s.addText("SCORE ≥ 6/10 = DEFINITE RHEUMATOID ARTHRITIS", { x:0.4,y:6.7,w:12.5,h:0.42, fontSize:13, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", margin:0});

  foot(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — TREATMENT OVERVIEW
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BG}, line:{color:LIGHT_BG}});
  hdr(s,"Treatment of Rheumatoid Arthritis","Treat-to-target: goal is remission or low disease activity");

  // Principle
  s.addShape(pres.shapes.RECTANGLE, { x:0.3,y:1.22,w:12.7,h:0.55, fill:{color:NAVY}, line:{color:NAVY}});
  s.addText([
    { text:"Treat-to-Target (T2T): ", options:{ bold:true, color:GOLD, fontSize:12 }},
    { text:"Target is remission (DAS28 <2.6) or low disease activity. Reassess every 1–3 months. Escalate DMARD therapy if target not met within 3–6 months.", options:{ color:WHITE, fontSize:12 }},
  ],{ x:0.45,y:1.22,w:12.4,h:0.55, valign:"middle", fontFace:"Calibri"});

  // Drug categories
  const cats = [
    { title:"NSAIDs", color:TEAL_LIGHT, tc:TEAL,
      points:["Adjunctive agents only (not disease-modifying)","COX-1 and COX-2 inhibition → analgesic + anti-inflammatory","Minimize chronic use: GI toxicity (peptic ulcer, gastritis), renal injury","Roughly equivalent efficacy; individual response varies"] },
    { title:"Glucocorticoids", color:"FFF3E0", tc:ORANGE,
      points:["Bridge therapy while DMARD takes effect (weeks–months)","Acute flare management: short burst (1–2 weeks)","Chronic low-dose: ≤5–10 mg/day prednisone","⚠ Long-term risks: osteoporosis, infection, metabolic effects","Intra-articular injection for mono/oligoarticular flare"] },
    { title:"csDMARDs (Conventional)", color:"E8F5E9", tc:GREEN,
      points:["Methotrexate (MTX): DRUG OF CHOICE for early RA","Start MTX 7.5–15 mg/week; up to 25 mg/week","Always supplement with folic acid","Other csDMARDs: hydroxychloroquine, sulfasalazine, leflunomide","Triple therapy (MTX + HCQ + SSZ) = proven superiority over MTX alone"] },
  ];
  cats.forEach((c,i)=>{
    const x=0.3+i*4.28;
    s.addShape(pres.shapes.RECTANGLE, { x,y:1.95,w:4.1,h:0.42, fill:{color:c.tc}, line:{color:c.tc}});
    s.addText(c.title, { x:x+0.1,y:1.95,w:3.9,h:0.42, fontSize:13, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x,y:2.37,w:4.1,h:2.35, fill:{color:LIGHT_BG}, line:{color:c.tc, pt:1.5}});
    const items=c.points.map((p,j)=>({ text:p, options:{ bullet:true, breakLine:j<c.points.length-1, fontSize:10.5, color:DARK_TEXT, fontFace:"Calibri"}}));
    s.addText(items, { x:x+0.12,y:2.43,w:3.86,h:2.23, valign:"top"});
  });

  // Biologic section header
  s.addShape(pres.shapes.RECTANGLE, { x:0.3,y:4.85,w:12.7,h:0.42, fill:{color:ACCENT}, line:{color:ACCENT}});
  s.addText("BIOLOGIC DMARDs (bDMARDs) — Used when csDMARDs are inadequate", { x:0.45,y:4.85,w:12.4,h:0.42, fontSize:13, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});

  const bios = [
    { n:"Anti-TNF", d:"Etanercept, Infliximab, Adalimumab, Certolizumab, Golimumab", c:ACCENT },
    { n:"Anti-IL-6R", d:"Tocilizumab, Sarilumab", c:TEAL },
    { n:"Anti-CD80/86", d:"Abatacept (CTLA4-Ig)\nT-cell co-stimulation blockade", c:PURPLE },
    { n:"Anti-CD20", d:"Rituximab\nB-cell depletion", c:GREEN },
    { n:"JAK Inhibitors", d:"Tofacitinib, Baricitinib, Upadacitinib\n(tsDMARDs — oral)", c:ORANGE },
  ];
  bios.forEach((b,i)=>{
    const x=0.3+i*2.55;
    s.addShape(pres.shapes.RECTANGLE, { x,y:5.27,w:2.42,h:0.4, fill:{color:b.c}, line:{color:b.c}});
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  });

  foot(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — DMARDs TABLE
// ═══════════════════════════════════════════════════════════════════════════════
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  hdr(s,"Key DMARDs — Dosing, Mechanism & Toxicity","Based on Table 370-3, Harrison's 22E");

  const hdr2 = ["Drug","Mechanism","Dose","Key Toxicities","Monitoring"];
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  const rows=[
    { drug:"Methotrexate",       mech:"Inhibits DHFR; anti-inflammatory via adenosine", dose:"7.5–25 mg/wk", tox:"Hepatotoxicity, mucositis, myelosuppression, teratogenic, pneumonitis", mon:"LFTs, CBC, Cr q4–8wk; avoid alcohol", c:GREEN},
    { drug:"Hydroxychloroquine", mech:"Inhibits TLR signalling, lysosomal acidification",   dose:"≤5 mg/kg/d",  tox:"Retinal toxicity (maculopathy)",                                        mon:"Annual ophthalmology exam", c:TEAL},
    { drug:"Sulfasalazine",      mech:"Anti-inflammatory; unknown exact mechanism",          dose:"1–1.5 g BID",  tox:"GI upset, rash, leukopenia, hepatitis",                                 mon:"CBC, LFTs q3mo", c:TEAL_LIGHT},
    { drug:"Leflunomide",        mech:"Inhibits pyrimidine synthesis (DHODH)",               dose:"20 mg/d",     tox:"Hepatotoxicity, HTN, teratogenic, diarrhea",                             mon:"LFTs, BP monthly × 6mo then q6mo", c:PURPLE},
    { drug:"Adalimumab",         mech:"Monoclonal Ab; neutralizes TNF-α",                   dose:"40 mg q2wk SC",tox:"Infection (TB reactivation), demyelination, lymphoma risk",             mon:"TB screen before start; CBC, LFTs", c:ACCENT},
    { drug:"Etanercept",         mech:"Fusion protein; binds TNF-α + TNF-β",                dose:"50 mg/wk SC", tox:"Injection site reactions, infection, heart failure",                      mon:"TB screen before start", c:ACCENT},
    { drug:"Tocilizumab",        mech:"Blocks IL-6 receptor (soluble + membrane-bound)",    dose:"162 mg/wk SC", tox:"↑ LFTs, ↑ lipids, GI perforation, cytopenias",                         mon:"LFTs, lipids, CBC q4–8wk", c:ORANGE},
    { drug:"Abatacept",          mech:"CTLA4-Ig; blocks CD80/CD86:CD28 co-stimulation",    dose:"SC weekly or IV monthly", tox:"Infection, COPD exacerbation",                               mon:"Watch for TB, hepatitis", c:PURPLE},
    { drug:"Rituximab",          mech:"Anti-CD20; depletes B lymphocytes",                  dose:"1000 mg IV ×2 (2wk apart)", tox:"Infusion reaction, PML (rare), immunosuppression",        mon:"Immunoglobulin levels before each cycle", c:GREEN},
    { drug:"Tofacitinib",        mech:"JAK1/3 inhibitor → blocks cytokine signalling",     dose:"5 mg BID oral",tox:"VTE (↑ risk), serious infection, CV risk, malignancy",                   mon:"CBC, LFTs, lipids; avoid with live vaccines", c:"8D6A9F"},
  ];
  rows.forEach((r,i)=>{
    const y=1.64+i*0.54;
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    s.addText(r.tox,  { x:hx[3]+0.05,y,w:hw[3]-0.1,h:0.54, fontSize:8, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
    s.addText(r.mon,  { x:hx[4]+0.05,y,w:hw[4]-0.1,h:0.54, fontSize:8, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
  });

  foot(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — TREATMENT ALGORITHM
// ═══════════════════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BG}, line:{color:LIGHT_BG}});
  hdr(s,"Treatment Algorithm","Step-up strategy with treat-to-target approach (Harrison's 22E + ACR 2021 Guidelines)");

  // Step boxes with arrows
  const steps = [
    { n:"STEP 1", t:"Diagnosis + Early DMARD Start", d:"Start MTX as soon as possible after diagnosis. Add folic acid.\nBridge with low-dose glucocorticoids if needed.", c:GREEN },
    { n:"STEP 2", t:"Reassess at 3 months", d:"If LDA/remission not achieved:\nEscalate MTX dose to maximum tolerated (25 mg/wk)\nConsider adding HCQ and/or SSZ (triple therapy)", c:TEAL },
    { n:"STEP 3", t:"Moderate–High Disease Activity persists", d:"Add biologic DMARD or JAK inhibitor to MTX:\nFirst choice: Anti-TNF agents (most data)\nAlternatives: abatacept, tocilizumab, rituximab", c:ACCENT },
    { n:"STEP 4", t:"Inadequate response / toxicity", d:"Switch biologic (different mechanism class)\nor switch to JAK inhibitor\nor trial of combination bDMARD strategies", c:PURPLE },
    { n:"STEP 5", t:"Refractory / Ongoing Activity", d:"Re-evaluate diagnosis\nReferral to tertiary rheumatology\nConsider clinical trial enrollment\nAddress comorbidities (CVD, osteoporosis)", c:ORANGE },
  ];
  steps.forEach((st,i)=>{
    const y=1.22+i*1.18;
    s.addShape(pres.shapes.RECTANGLE, { x:0.3,y,w:1.2,h:0.9, fill:{color:st.c}, line:{color:st.c}});
    s.addText(st.n, { x:0.3,y,w:1.2,h:0.9, fontSize:11, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", margin:0});
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    s.addText(st.t, { x:1.58,y,w:2.84,h:0.9, fontSize:12, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
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    s.addText(st.d, { x:4.62,y:y+0.04,w:8.33,h:0.82, fontSize:11, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
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      s.addShape(pres.shapes.RECTANGLE, { x:0.82,y:y+0.9,w:0.16,h:0.28, fill:{color:st.c}, line:{color:st.c}});
    }
  });

  // Key principle box
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  s.addText("Key principle: Escalate therapy every 3 months if treatment target (remission / LDA) not achieved  |  Combination > Monotherapy in most patients", {
    x:0.4,y:7.08,w:12.5,h:0.35, fontSize:9.5, color:GOLD, bold:true, valign:"middle", fontFace:"Calibri", margin:0});
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — DISEASE ACTIVITY INDICES & MONITORING
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.shapes.RECTANGLE, { x:0,y:0,w:13.3,h:7.5, fill:{color:LIGHT_BG}, line:{color:LIGHT_BG}});
  hdr(s,"Disease Activity Measurement & Monitoring","Tools for tracking RA and guiding treatment decisions");

  // Indices
  s.addShape(pres.shapes.RECTANGLE, { x:0.3,y:1.22,w:6.2,h:0.42, fill:{color:TEAL}, line:{color:TEAL}});
  s.addText("Disease Activity Indices", { x:0.4,y:1.22,w:6.0,h:0.42, fontSize:13, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});

  const indices = [
    { name:"DAS28 (Disease Activity Score)", comp:"28 tender + swollen joint counts, ESR/CRP, patient VAS", use:"<2.6 = remission; 2.6–3.2 = LDA; 3.2–5.1 = MDA; >5.1 = HDA", c:TEAL },
    { name:"SDAI (Simplified DA Index)",      comp:"28 SJC + 28 TJC + patient VAS + physician VAS + CRP",   use:"≤3.3 = remission; 3.4–11 = LDA", c:GREEN },
    { name:"CDAI (Clinical DA Index)",        comp:"28 SJC + 28 TJC + patient VAS + physician VAS (no labs)", use:"≤2.8 = remission; 2.9–10 = LDA; useful in clinical practice", c:PURPLE },
    { name:"ACR 20/50/70 Response",           comp:"20/50/70% improvement in joint counts + 3 of 5 other measures", use:"Primary endpoint in clinical trials", c:ORANGE },
    { name:"RAPID3",                          comp:"Patient self-report only (no joint counts)", use:"Simple; for busy clinical settings", c:TEAL_LIGHT },
  ];
  indices.forEach((r,i)=>{
    const y=1.64+i*0.9;
    s.addShape(pres.shapes.RECTANGLE, { x:0.3,y,w:2.6,h:0.9, fill:{color:r.c}, line:{color:r.c}});
    s.addText(r.name, { x:0.38,y,w:2.44,h:0.9, fontSize:9.5, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:2.9,y,w:1.8,h:0.9, fill:{color:LIGHT_BG}, line:{color:r.c, pt:1}});
    s.addText(r.comp, { x:2.97,y,w:1.66,h:0.9, fontSize:8.5, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
    s.addShape(pres.shapes.RECTANGLE, { x:4.7,y,w:1.8,h:0.9, fill:{color:LIGHT_BG}, line:{color:r.c, pt:1}});
    s.addText(r.use, { x:4.77,y,w:1.66,h:0.9, fontSize:8.5, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
  });

  // Monitoring right panel
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  s.addText("Ongoing Monitoring of RA Patients", { x:6.85,y:1.22,w:6.05,h:0.42, fontSize:13, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});

  const monitors = [
    { cat:"Clinical", items:"Joint counts (TJC/SJC), morning stiffness duration, functional disability (HAQ), patient VAS, physician global assessment" },
    { cat:"Laboratory", items:"CRP, ESR, CBC, LFTs, creatinine — frequency depends on DMARD used (q4–8 weeks when initiating, then q3 months)" },
    { cat:"Imaging", items:"X-rays of hands/feet at baseline and annually to detect erosions. MRI/ultrasound more sensitive for early erosions and synovitis" },
    { cat:"Comorbidities", items:"Cardiovascular risk (RA doubles CV mortality) — screen lipids, BP. Osteoporosis screening — DEXA scan. Infection risk — vaccinate (flu, pneumococcal, zoster)" },
    { cat:"Drug Toxicity", items:"MTX: LFTs, CBC, creatinine. Anti-TNF: TB screen, hepatitis B, infection surveillance. JAK inhibitors: lipids, VTE risk, CBC" },
  ];
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    const y=1.64+i*0.95;
    const c=i%2===0?ACCENT:PURPLE;
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    s.addText(m.cat, { x:6.78,y,w:1.34,h:0.95, fontSize:10, bold:true, color:WHITE, valign:"middle", fontFace:"Calibri", margin:0});
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    s.addText(m.items, { x:8.22,y,w:4.72,h:0.95, fontSize:9.5, color:DARK_TEXT, valign:"middle", fontFace:"Calibri", margin:0});
  });

  foot(s);
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — KEY TAKE-AWAYS
// ═══════════════════════════════════════════════════════════════════════════════
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  s.addShape(pres.shapes.RECTANGLE, { x:0,y:1.08,w:13.3,h:0.06, fill:{color:ACCENT}, line:{color:ACCENT}});
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  s.addText("KEY TAKE-AWAYS", {
    x:0.5,y:0.18,w:12.3,h:0.82, fontSize:28, bold:true, color:WHITE, align:"center", fontFace:"Calibri", charSpacing:8});

  const pts = [
    { n:"1", t:"RA is a symmetric polyarthritis", d:"Predominantly small joints (MCP, PIP, wrists). Morning stiffness >1 hour is hallmark. DIP sparing differentiates from OA.", c:TEAL },
    { n:"2", t:"RF + Anti-CCP (ACPA)", d:"ACPA is highly specific (~95%) and predictive of erosive disease. Present years before symptoms = preclinical RA.", c:PURPLE },
    { n:"3", t:"2010 ACR/EULAR criteria", d:"Score ≥6/10 = definite RA. Domains: joint involvement, serology, acute-phase reactants, symptom duration.", c:GREEN },
    { n:"4", t:"Methotrexate is drug of first choice", d:"csDMARD of choice for early RA. Always give folic acid. Escalate to 25 mg/wk. Triple therapy > monotherapy.", c:GOLD },
    { n:"5", t:"Treat-to-Target (T2T)", d:"Reassess every 1–3 months. Escalate if target (remission/LDA) not met within 3–6 months.", c:ACCENT },
    { n:"6", t:"Biologics for inadequate csDMARD response", d:"Anti-TNF agents are first-line biologics. Alternatives: tocilizumab, abatacept, rituximab. Oral JAK inhibitors available.", c:TEAL_LIGHT },
    { n:"7", t:"Screen before biologics", d:"TB, hepatitis B, varicella screen mandatory. Do not start anti-TNF in active infection.", c:ORANGE },
    { n:"8", t:"RA doubles cardiovascular mortality", d:"Monitor and treat CV risk factors aggressively. Osteoporosis prophylaxis in steroid users.", c:ACCENT },
  ];

  pts.forEach((p,i)=>{
    const col=i<4?0:1;
    const row=i<4?i:i-4;
    const x=col===0?0.3:6.85;
    const y=1.22+row*1.35;
    const w=6.25;
    s.addShape(pres.shapes.RECTANGLE, { x,y,w:0.65,h:1.2, fill:{color:p.c}, line:{color:p.c}});
    s.addText(p.n, { x,y,w:0.65,h:1.2, fontSize:22, bold:true, color:WHITE, align:"center", valign:"middle", fontFace:"Calibri", margin:0});
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  s.addText("Source: Harrison's Principles of Internal Medicine 22E (2025)  |  Chapter 370: Rheumatoid Arthritis", {
    x:0,y:6.98,w:13.3,h:0.5, fontSize:9, color:GRAY, align:"center", valign:"middle", fontFace:"Calibri"});
}

// ─── WRITE ────────────────────────────────────────────────────────────────────
pres.writeFile({ fileName:"/home/daytona/workspace/ascites-ppt/RA_Harrisons_22E.pptx" })
  .then(()=> console.log("SUCCESS: RA_Harrisons_22E.pptx"))
  .catch(err=>{ console.error("ERROR:",err); process.exit(1); });

cd /home/daytona/workspace/ascites-ppt && node create_ra_ppt.js

EULAR recommendations management rheumatoid arthritis

EULAR 2024 rheumatoid arthritis management guidelines update

https://www.news-medical.net/news/20260313/Updated-EULAR-rec…

EULAR recommendations rheumatoid arthritis DMARDs 2025 update Smolen

Smolen EULAR 2025 RA recommendations annals rheumatic diseases DOI 10.1016/j.ard.2026.01.023

PMID: 41826212

PMID: 41997804

PMID: 41951459

https://www.guidelinecentral.com/guideline/5135295

A professional clinical treatment flowchart for Rheumatoid Arthritis management based on EULAR 2025 recommendations. Clean white background, medical style, color-coded boxes with arrows. Title at top: "RHEUMATOID ARTHRITIS: Treatment Algorithm" with subtitle "EULAR 2025 Recommendations | Smolen et al., Ann Rheum Dis 2026" The flowchart flows top-to-bottom with clear arrows: START BOX (dark navy blue, rounded): "NEW DIAGNOSIS OF RA" with note: "Start DMARDs IMMEDIATELY after diagnosis" ↓ arrow STEP 1 BOX (green): "FIRST-LINE: csDMARD Therapy" • Methotrexate (MTX) — drug of first choice • If MTX contraindicated: Leflunomide or Sulfasalazine • Add short-term Glucocorticoids as bridge (taper ASAP) • Add Folic acid with MTX ↓ arrow DECISION DIAMOND (orange): "Reassess at 3 months — Target achieved? (Remission or LDA)" Two branches: → YES branch (right side, green): "CONTINUE current therapy. Monitor every 1–3 months. If sustained remission → prefer DMARD continuation; dose reduction may be considered" → NO branch (downward, red): "Not at target by 3–6 months → ESCALATE" ↓ from NO STEP 2 BOX (blue): "ADD bDMARD (preferred) or consider JAKi" Preferred bDMARDs: • Anti-TNF: Adalimumab, Etanercept, Infliximab, Certolizumab, Golimumab • Abatacept (anti-CD80/86) • Tocilizumab / Sarilumab (IL-6 inhibitors) • Rituximab (anti-CD20) JAK Inhibitors (assess risk first): ⚠ Screen for: MACE risk, VTE/PE risk, malignancy history, age >65, heavy smoker • Tofacitinib, Baricitinib, Filgotinib, Upadacitinib Important note box (yellow): "Combine bDMARD/JAKi with csDMARD. If csDMARD not tolerated: IL-6i or JAKi preferred (effective as monotherapy)" ↓ arrow DECISION DIAMOND (orange): "Response adequate? Target reached?" → YES (green right branch): "Continue. Sustained remission → prefer continuation, reduce dose cautiously" → NO (red downward): "bDMARD or JAKi failure" ↓ STEP 3 BOX (purple): "SWITCH bDMARD or JAKi" • Switch to different class bDMARD, OR • Switch within same class, OR • Switch to JAKi (if not used; assess risks) • Both within-class and between-class switching acceptable ↓ arrow BOTTOM BOX (dark navy): "Throughout all steps: Reassess every 1–3 months | Glucocorticoids: bridge only — taper and stop | Shared decision-making with patient at every step" Small red warning box on side: "⚠ JAKi Risk Factors — Assess before use: Age >65 | Cardiovascular disease | Prior malignancy | VTE/Pulmonary embolism history | Long-term smoker" The flowchart uses color-coded sections: green for first-line, blue for second-line, purple for third-line, orange for decision points, red arrows for failure paths, green arrows for success paths.