const {
  Document, Packer, Paragraph, TextRun, Table, TableRow, TableCell,
  HeadingLevel, AlignmentType, BorderStyle, WidthType, VerticalAlign,
  ShadingType, PageNumber, NumberFormat, Header, Footer,
  TableOfContents, LevelFormat, convertInchesToTwip
} = require('docx');
const fs = require('fs');

// ─── Color palette ────────────────────────────────────────────────────────
const BURGUNDY = "7B1C35";
const LIGHT_BURGUNDY = "A94060";
const BG_LIGHT = "F9F0F3";
const TABLE_HEADER_BG = "7B1C35";
const TABLE_ALT_ROW = "F5E8EC";
const WHITE = "FFFFFF";
const DARK_GRAY = "2D2D2D";
const MID_GRAY = "555555";

// ─── Helpers ──────────────────────────────────────────────────────────────
function heading1(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_1,
    spacing: { before: 360, after: 120 },
    border: {
      bottom: { style: BorderStyle.SINGLE, size: 4, color: BURGUNDY, space: 4 }
    }
  });
}

function heading2(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_2,
    spacing: { before: 240, after: 80 }
  });
}

function heading3(text) {
  return new Paragraph({
    text,
    heading: HeadingLevel.HEADING_3,
    spacing: { before: 160, after: 60 }
  });
}

function para(runs, spacing = { before: 60, after: 80 }) {
  return new Paragraph({ children: runs, spacing });
}

function text(str, options = {}) {
  return new TextRun({ text: str, font: "Calibri", size: 22, color: DARK_GRAY, ...options });
}

function bold(str, color = DARK_GRAY, size = 22) {
  return new TextRun({ text: str, bold: true, font: "Calibri", size, color });
}

function bullet(runs, level = 0) {
  return new Paragraph({
    children: runs,
    bullet: { level },
    spacing: { before: 40, after: 40 }
  });
}

function spacer(lines = 1) {
  return new Paragraph({ text: "", spacing: { before: 0, after: lines * 100 } });
}

function colorBox(labelText, bodyText, bgColor = BG_LIGHT) {
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    borders: {
      top: { style: BorderStyle.SINGLE, size: 6, color: BURGUNDY },
      bottom: { style: BorderStyle.SINGLE, size: 2, color: BURGUNDY },
      left: { style: BorderStyle.SINGLE, size: 6, color: BURGUNDY },
      right: { style: BorderStyle.SINGLE, size: 2, color: BURGUNDY },
      insideHorizontal: { style: BorderStyle.NONE },
      insideVertical: { style: BorderStyle.NONE }
    },
    rows: [
      new TableRow({
        children: [
          new TableCell({
            shading: { fill: bgColor, type: ShadingType.CLEAR },
            margins: { top: 120, bottom: 120, left: 200, right: 200 },
            children: [
              new Paragraph({
                children: [bold(labelText + "  ", BURGUNDY, 22), text(bodyText)],
                spacing: { before: 40, after: 40 }
              })
            ]
          })
        ]
      })
    ]
  });
}

// Two-column table helper
function twoColTable(rows, headerRow = null) {
  const tRows = [];
  if (headerRow) {
    tRows.push(new TableRow({
      tableHeader: true,
      children: headerRow.map(cell => new TableCell({
        shading: { fill: TABLE_HEADER_BG, type: ShadingType.CLEAR },
        margins: { top: 80, bottom: 80, left: 160, right: 160 },
        children: [new Paragraph({
          children: [bold(cell, WHITE, 22)],
          alignment: AlignmentType.CENTER
        })]
      }))
    }));
  }
  rows.forEach((row, ri) => {
    tRows.push(new TableRow({
      children: row.map((cell, ci) => new TableCell({
        shading: { fill: ri % 2 === 0 ? WHITE : TABLE_ALT_ROW, type: ShadingType.CLEAR },
        margins: { top: 80, bottom: 80, left: 160, right: 160 },
        children: [new Paragraph({
          children: [ci === 0 ? bold(cell, DARK_GRAY) : text(cell)],
          alignment: ci === 0 ? AlignmentType.LEFT : AlignmentType.LEFT
        })]
      }))
    }));
  });
  return new Table({
    width: { size: 100, type: WidthType.PERCENTAGE },
    borders: {
      top: { style: BorderStyle.SINGLE, size: 4, color: BURGUNDY },
      bottom: { style: BorderStyle.SINGLE, size: 4, color: BURGUNDY },
      left: { style: BorderStyle.NONE },
      right: { style: BorderStyle.NONE },
      insideHorizontal: { style: BorderStyle.SINGLE, size: 2, color: "DDDDDD" },
      insideVertical: { style: BorderStyle.NONE }
    },
    rows: tRows
  });
}

// ─── Cover / Title Block ──────────────────────────────────────────────────
const titleBlock = new Table({
  width: { size: 100, type: WidthType.PERCENTAGE },
  borders: {
    top: { style: BorderStyle.NONE }, bottom: { style: BorderStyle.NONE },
    left: { style: BorderStyle.NONE }, right: { style: BorderStyle.NONE },
    insideHorizontal: { style: BorderStyle.NONE }, insideVertical: { style: BorderStyle.NONE }
  },
  rows: [
    new TableRow({
      children: [new TableCell({
        shading: { fill: BURGUNDY, type: ShadingType.CLEAR },
        margins: { top: 400, bottom: 400, left: 400, right: 400 },
        children: [
          new Paragraph({
            children: [new TextRun({ text: "CASE PAPER PRESENTATION", bold: true, font: "Calibri", size: 28, color: WHITE, allCaps: true })],
            alignment: AlignmentType.CENTER,
            spacing: { after: 80 }
          }),
          new Paragraph({
            children: [new TextRun({ text: "Uterine Fibroids (Leiomyoma):", bold: true, font: "Calibri", size: 40, color: WHITE })],
            alignment: AlignmentType.CENTER,
            spacing: { after: 60 }
          }),
          new Paragraph({
            children: [new TextRun({ text: "Impact on Women's Health and Quality of Life", bold: true, font: "Calibri", size: 34, color: "FFCCD8" })],
            alignment: AlignmentType.CENTER,
            spacing: { after: 160 }
          }),
          new Paragraph({
            children: [new TextRun({ text: "Department of Obstetrics & Gynaecology", font: "Calibri", size: 22, color: "FFCCD8", italics: true })],
            alignment: AlignmentType.CENTER,
            spacing: { after: 40 }
          }),
          new Paragraph({
            children: [new TextRun({ text: "Gynaecology Residency Case Presentation  |  May 2026", font: "Calibri", size: 20, color: "FFCCD8" })],
            alignment: AlignmentType.CENTER
          })
        ]
      })]
    })
  ]
});

// ─── ABSTRACT ─────────────────────────────────────────────────────────────
const abstractSection = [
  heading1("Abstract"),
  colorBox("Background:", "Uterine leiomyomas (fibroids) are the most common benign gynaecological tumours, affecting up to 70% of women by age 50. Despite their benign nature, fibroids impose a substantial burden on women's health through heavy menstrual bleeding, pelvic pain, urinary symptoms, fertility impairment, and severe deterioration in quality of life (QoL)."),
  spacer(),
  colorBox("Case Summary:", "A 34-year-old nulliparous woman presented with a 2-year history of heavy menstrual bleeding, progressive pelvic pressure, urinary frequency, and fatigue. Investigations revealed multiple intramural and submucous leiomyomas with secondary iron-deficiency anaemia. Management encompassed medical optimisation and definitive laparoscopic myomectomy."),
  spacer(),
  colorBox("Conclusion:", "This case illustrates how symptomatic fibroids can remain under-recognised for years, with a cumulative and multi-dimensional impact on physical and psychosocial QoL. Early diagnosis, patient-centred shared decision-making, and awareness of validated QoL tools are essential in gynaecological practice."),
  spacer(2)
];

// ─── CASE PRESENTATION ────────────────────────────────────────────────────
const caseSection = [
  heading1("1. Case Presentation"),

  heading2("1.1  Patient Profile"),
  twoColTable([
    ["Age / Gender", "34 years / Female"],
    ["Parity", "G0 P0 (nulliparous, keen to preserve fertility)"],
    ["BMI", "24.6 kg/m²"],
    ["Occupation", "School teacher"],
    ["Menstrual History", "Regular cycles, 5-7 days heavy flow; cycle length 25-28 days"],
    ["Duration of Symptoms", "Approximately 2 years"],
    ["Past Medical History", "Nil significant; no coagulopathy"],
    ["Past Surgical History", "Nil"],
    ["Family History", "Mother: hysterectomy for fibroids at age 40"],
    ["Medications", "Ferrous sulphate 200 mg OD (self-initiated)"]
  ], ["Parameter", "Detail"]),
  spacer(),

  heading2("1.2  Chief Complaints"),
  bullet([bold("1. ", BURGUNDY), text("Heavy menstrual bleeding (HMB): ")], 0),
  bullet([text("Soaking >8 pads/day during heaviest flow; passing clots; flooding episodes")], 1),
  bullet([text("Severe enough to disrupt work and social activities on cycle days 1-3")], 1),
  bullet([bold("2. ", BURGUNDY), text("Pelvic pain and pressure:")], 0),
  bullet([text("Dull, dragging lower abdominal ache; worsening dysmenorrhoea (VAS 7/10)")], 1),
  bullet([text("Sense of pelvic fullness and 'heaviness' even between periods")], 1),
  bullet([bold("3. ", BURGUNDY), text("Urinary symptoms:")], 0),
  bullet([text("Urinary frequency (voiding every 1-2 hours); no dysuria; no stress incontinence")], 1),
  bullet([bold("4. ", BURGUNDY), text("Fatigue and exertional dyspnoea:")], 0),
  bullet([text("Progressive tiredness, pallor, and reduced exercise tolerance")], 1),
  bullet([bold("5. ", BURGUNDY), text("Psychosocial distress:")], 0),
  bullet([text("Anxiety around heavy periods, fear of social embarrassment; reduced sexual intimacy due to dyspareunia and bloating")], 1),
  bullet([text("Concerns about fertility and impact on career")], 1),
  spacer(),

  heading2("1.3  Clinical Examination"),
  twoColTable([
    ["General", "Pallor +++, no jaundice/oedema; HR 96 bpm, BP 110/70 mmHg"],
    ["Abdomen", "Soft, irregular firm mass palpable to umbilicus, non-tender; no ascites"],
    ["Bimanual Pelvic Exam", "Uterus enlarged (~16-week size), firm, irregular, non-tender; no adnexal mass; cervix normal"]
  ], ["System", "Findings"]),
  spacer(),

  heading2("1.4  Investigations"),
  twoColTable([
    ["Haemoglobin", "7.8 g/dL (Iron-deficiency anaemia)"],
    ["MCV / Serum Ferritin", "62 fL / 4 µg/L"],
    ["Peripheral Blood Film", "Microcytic hypochromic anaemia"],
    ["Serum Beta-hCG", "Negative (pregnancy excluded)"],
    ["TSH", "2.1 mIU/L (normal)"],
    ["Coagulation screen (PT/aPTT)", "Normal (von Willebrand disease excluded clinically)"],
    ["Pap Smear", "NILM (normal)"],
    ["Pelvic Ultrasound (TVS)", "Uterus 14×10×9 cm; multiple intramural fibroids (largest 6.2 cm posterior wall); one submucous fibroid (FIGO Type 1, 3.5 cm); no adnexal pathology; endometrium 8 mm (proliferative)"],
    ["MRI Pelvis", "Confirmed: 4 intramural fibroids, largest 6.2 cm; 1 FIGO Type 1 submucosal fibroid 3.5 cm; no features of degeneration/malignancy; normal endometrial stripe"],
    ["Saline Infusion Sonography (SIS)", "Confirms submucous fibroid Type 1 — 50% intracavitary protrusion"],
    ["Endometrial Biopsy", "Proliferative endometrium, no hyperplasia/malignancy"]
  ], ["Investigation", "Result"]),
  spacer(),

  heading2("1.5  QoL Assessment Tools Used"),
  para([text("Validated questionnaires applied at baseline to quantify the burden:")]),
  twoColTable([
    ["UFS-QoL", "Uterine Fibroid Symptom and Quality of Life questionnaire — disease-specific; most widely used. Symptom Severity Score 72/100 (severely symptomatic)."],
    ["SF-36", "Generic QoL — Social Functioning, Role-Physical, and Vitality subscores all in lowest quartile; comparable to women with heart disease or COPD."],
    ["PBAC Score", "Pictorial Blood Assessment Chart: score 642 (severe HMB; threshold for clinical significance >100)"],
    ["VAS Pain", "Dysmenorrhoea 7/10; non-cyclic pelvic pain 4/10; dyspareunia 5/10"]
  ], ["Tool", "Findings"]),
  spacer(2)
];

// ─── LITERATURE REVIEW ────────────────────────────────────────────────────
const literatureSection = [
  heading1("2. Review of Literature"),

  heading2("2.1  Epidemiology and Burden"),
  para([text("Uterine leiomyomas are the most common benign solid tumours in women of reproductive age. Cumulative incidence by age 50 reaches 70% in White women and up to 80% in Black women, who also present earlier, with more fibroids, larger fibroids, and more severe symptoms "), bold("(Sabiston, 2023; Berek & Novak's Gynecology)", MID_GRAY), text(".")]),
  para([text("Globally, fibroids are responsible for 30% of hysterectomies and considerable morbidity without mortality. Among women with fibroids, quality-of-life scores on the SF-36 are significantly worse than those of women with hypertension, heart disease, chronic lung disease, or arthritis "), bold("(Berek & Novak's, p. 503)", MID_GRAY), text(".")]),
  spacer(),

  heading2("2.2  Pathogenesis"),
  para([text("Fibroids are monoclonal smooth muscle tumours arising from the myometrium. Current evidence supports a multi-hit model:")]),
  bullet([bold("Hormonal dependency: ", BURGUNDY), text("Oestrogen and progesterone both stimulate fibroid growth. Oestrogen upregulates progesterone receptors; progesterone promotes mitogenic activity. Post-menopausal regression confirms hormone-dependence.")]),
  bullet([bold("Genetic mutations: ", BURGUNDY), text("Somatic mutations in MED12 (mediator complex subunit 12) are present in ~70% of fibroids. HMGA2 rearrangements and FH (fumarate hydratase) loss-of-function mutations account for further subgroups.")]),
  bullet([bold("Tissue injury hypothesis: ", BURGUNDY), text("Repetitive injury to the endometrium through menstruation may release growth factors that promote monoclonal proliferation. Berek & Novak's also identifies racial disparities in myometrial trauma repair as a contributor to higher incidence in Black women.")]),
  bullet([bold("Growth factors: ", BURGUNDY), text("TGF-β, EGF, IGF-I, VEGF, bFGF promote fibroid growth and angiogenesis within tumour stroma.")]),
  spacer(),

  heading2("2.3  Classification: FIGO System"),
  para([text("The FIGO (International Federation of Gynaecology and Obstetrics) leiomyoma classification system stratifies fibroids by location, guiding both symptom prediction and surgical approach:")]),
  twoColTable([
    ["Type 0", "Pedunculated intracavitary — entirely within cavity"],
    ["Type 1", "Submucosal — <50% intramural extension; strongly associated with HMB and anaemia"],
    ["Type 2", "Submucosal — ≥50% intramural extension"],
    ["Types 3, 4, 5", "Intramural — within uterine wall; associated with bulk symptoms as size increases"],
    ["Type 6", "Subserosal — <50% serosal contact"],
    ["Type 7", "Subserosal pedunculated — risk of torsion"],
    ["Type 8", "Cervical / extrauterine (parasitic, broad ligament)"]
  ], ["FIGO Type", "Description"]),
  para([text("Source: Sabiston Textbook of Surgery, Table 120.5; Munro MG et al., FIGO classification 2011.", MID_GRAY), new TextRun({ text: "" })]),
  spacer(),

  heading2("2.4  Symptoms and Their Impact on QoL"),

  heading3("2.4.1  Heavy Menstrual Bleeding (HMB)"),
  para([text("HMB is the most common complaint, primarily associated with submucosal fibroids (FIGO Types 0-2). Mechanisms include increased endometrial surface area, impaired endometrial haemostasis, abnormal vascularity, and altered prostaglandin metabolism. Women with fibroids use on average 7.5 pads/tampons on the heaviest day of flow vs. 6.1 in controls; those with fibroids >5 cm use ~3 more pads "), bold("(Berek & Novak's, p. 504)", MID_GRAY), text(". Resultant iron-deficiency anaemia is a common finding, with Hb <12 g/dL significantly associated with submucous fibroid type 0 in one large series (n=1,665 women)")]),
  spacer(),

  heading3("2.4.2  Pelvic Pain"),
  para([text("Pelvic pain from fibroids arises from multiple mechanisms: (1) mass effect and capsular distension, (2) degeneration (red, hyaline, cystic, calcific), (3) torsion of pedunculated fibroids, and (4) ischaemia. A population-based cohort of 635 women found that those with fibroids were only slightly more likely to report moderate/severe dyspareunia or non-cyclic pelvic pain, and had no increased rate of dysmenorrhoea "), bold("(Berek & Novak's, p. 504)", MID_GRAY), text(". However, clinically presenting women tend to report significantly higher pain scores, reflecting referral bias.")]),
  spacer(),

  heading3("2.4.3  Bulk/Pressure Symptoms"),
  para([text("Large or multiple intramural fibroids exert extrinsic pressure on adjacent pelvic organs:")]),
  bullet([bold("Bladder: ", BURGUNDY), text("Urinary frequency, urgency, and nocturia. Following UAE with 35% uterine volume reduction, frequency/urgency improved in 68% of women; unchanged or worse in only 14% "), bold("(Berek & Novak's, p. 505)", MID_GRAY)]),
  bullet([bold("Rectum: ", BURGUNDY), text("Constipation, tenesmus, and difficult defaecation with posterior wall fibroids. Pelvic floor dysfunction is increasingly recognised — a 2023 systematic review (Gupta et al., PMID 37411023) documented significant improvement in bladder and bowel symptoms after procedural interventions.")]),
  bullet([bold("Venous: ", BURGUNDY), text("Large fibroids can compress pelvic veins, leading to lower limb oedema or deep vein thrombosis (rare).")]),
  spacer(),

  heading3("2.4.4  Fertility and Reproductive Outcomes"),
  para([text("Submucosal fibroids distorting the cavity are clearly associated with impaired implantation, higher miscarriage rates, and reduced IVF success. Intramural fibroids >3 cm may reduce implantation rates by up to 23% (Somigliana et al.). During pregnancy, fibroids are detected in 3%-4% of midtrimester ultrasounds "), bold("(Creasy & Resnik's, p. 625)", MID_GRAY), text(". Fibroid degeneration during pregnancy causes acute pelvic pain and rarely stimulates contractions. Obstetric complications include malpresentation, placenta previa, preterm labour, and increased caesarean section rate.")]),
  spacer(),

  heading3("2.4.5  Mental Health and Psychosocial QoL"),
  para([text("A landmark 2024 systematic review by Neumann et al. (67 studies; 18 RCTs + 49 observational cohorts) concluded that fibroids 'significantly impact the quality of life and mental health of affected women' and that "), bold("all interventions were associated with significant improvement in both UFS-QoL and mental health metrics "), text("(PMID 38246400; Fertil Steril 2024). Domains affected include:")]),
  bullet([text("Anxiety, depression, and emotional distress (especially around unpredictable heavy periods)")]),
  bullet([text("Role impairment — absenteeism from work, reduced social participation, avoidance of exercise")]),
  bullet([text("Sexual dysfunction — dyspareunia, reduced libido, body-image concerns related to abdominal distension")]),
  bullet([text("Reproductive anxiety — fear regarding fertility, pressure regarding treatment decisions")]),
  spacer(),

  heading2("2.5  Diagnosis"),
  twoColTable([
    ["Clinical examination", "Enlarged, firm, irregular non-tender uterus on bimanual exam. Correlates well with uterine weight at pathology even in BMI >30."],
    ["Transvaginal ultrasound (TVS)", "First-line imaging. Well-defined hypoechoic masses; identifies location, size, number, vascularisation."],
    ["Saline Infusion Sonography (SIS)", "Best for delineating submucosal component; distinguishes FIGO types 0, 1, 2."],
    ["MRI pelvis", "Gold standard for mapping multiple fibroids, degeneration, adenomyosis co-existence, and pre-surgical planning."],
    ["Hysteroscopy", "Diagnostic and therapeutic for intracavitary and submucous fibroids."],
    ["Endometrial biopsy", "Mandatory to exclude endometrial malignancy in women with AUB."]
  ], ["Method", "Role"]),
  spacer(),

  heading2("2.6  Management Overview"),
  para([text("Management is guided by symptom severity, uterine size, fibroid location, reproductive intentions, patient preference, and access to interventions. The following framework reflects current evidence:")]),

  heading3("2.6.1  Medical Management"),
  twoColTable([
    ["Tranexamic acid", "Anti-fibrinolytic; reduces HMB by ~50% without hormonal effect; first-line non-hormonal option."],
    ["NSAIDs (mefenamic acid, naproxen)", "Reduces dysmenorrhoea and HMB; useful adjunct."],
    ["LNG-IUS (Mirena)", "Effective for HMB and pain in women with a non-distorted cavity; reduces need for surgery."],
    ["Combined OCP / Progestins", "Useful for cycle control; limited fibroid-reducing effect."],
    ["GnRH agonists (leuprolide)", "Reduce fibroid volume by 30-60% in 3-6 months; used pre-operatively. Effects reversible on cessation."],
    ["GnRH antagonists (elagolix, relugolix)", "Oral; rapid-onset. Relugolix 40 mg + add-back (E2/NETA) reduces HMB and preserves bone (PMID 37385088; N Engl J Med 2021)."],
    ["Selective Progesterone Receptor Modulators (e.g., ulipristal acetate)", "Effective for fibroid shrinkage and HMB control; RESTRICTED due to rare hepatotoxicity risk (EMA 2020). Use only under hepatic monitoring protocols."],
    ["Mifepristone (anti-progestogen)", "5-10 mg/day for 3-6 months; reduces symptoms and fibroid size; not yet globally licensed for this indication."]
  ], ["Agent", "Notes"]),
  spacer(),

  heading3("2.6.2  Procedural/Minimally Invasive Interventions"),
  twoColTable([
    ["Hysteroscopic myomectomy", "First-line surgical treatment for FIGO Types 0-2. Preserves uterus; corrects HMB; suitable day-case procedure."],
    ["Laparoscopic myomectomy", "For intramural and subserosal fibroids (Types 3-7) in fertility-sparing candidates. Superior recovery vs. open."],
    ["Open (abdominal) myomectomy", "For large, multiple, or deep intramural fibroids not amenable to laparoscopy."],
    ["Uterine Artery Embolization (UAE)", "Interventional radiology; 28% subsequent hysterectomy rate at 5 years (Manyonda et al. NEJM 2020); not recommended if fertility desired."],
    ["Focused Ultrasound Surgery (HIFU/MRgFUS)", "Non-invasive; QoL and symptom improvement documented (Yan et al. PMID 35094613). Limited availability."],
    ["Radiofrequency Ablation (RFA)", "Transcervical or laparoscopic; AAGL systematic review (PMID 39277104, 2025) shows significant symptom reduction; fibroid volume reduction ~50%."],
    ["Endometrial Ablation", "Adjunct for HMB in absence of cavity-distorting fibroids; not suitable if fertility desired."]
  ], ["Procedure", "Indications / Evidence"]),
  spacer(),

  heading3("2.6.3  Definitive Surgery"),
  para([text("Hysterectomy (total/subtotal; abdominal, vaginal, laparoscopic, or robotic) remains the definitive treatment for completed families with severe symptoms or failed conservative management. Goldman-Cecil Medicine notes that "), bold('"The definitive treatment for fibroids is hysterectomy, but less invasive options are often preferable"'), text(". Power morcellation during laparoscopic hysterectomy/myomectomy has fallen out of favour due to the low but real risk of disseminating occult leiomyosarcoma "), bold("(Goldman-Cecil, p. 486)", MID_GRAY), text(".")]),
  spacer(2)
];

// ─── CASE DISCUSSION ──────────────────────────────────────────────────────
const discussionSection = [
  heading1("3. Discussion"),

  heading2("3.1  Correlating Case Findings with Literature"),
  para([text("This patient's presentation exemplifies the prototypical symptomatic fibroid burden: a nulliparous woman in her mid-thirties, with a strong family history (autosomal predisposition is recognised), severe HMB causing symptomatic anaemia (Hb 7.8 g/dL), bulk symptoms, impaired fertility concerns, and significant QoL deterioration across physical, psychological, and social domains.")]),
  para([text("The 2-year delay before specialist evaluation is consistent with international data showing that women with fibroids often endure symptoms for 3-4 years before receiving a diagnosis, often normalising heavy periods as a physiological variant. This delay has direct consequences - worsening anaemia, missed fertility windows, accumulating psychosocial burden, and progressive fibroid growth.")]),
  spacer(),

  heading2("3.2  Why QoL Deterioration is Multi-Dimensional"),
  para([text("Using validated tools (UFS-QoL, SF-36, PBAC, VAS) at baseline clarifies the true burden:")]),
  bullet([bold("Physical domain: ", BURGUNDY), text("Severe iron-deficiency anaemia impairs cognitive function, exercise tolerance, and immune competence. PBAC score of 642 objectively confirms HMB beyond the threshold for clinical intervention.")]),
  bullet([bold("Psychological domain: ", BURGUNDY), text("The patient's anxiety around unpredictable flooding, reproductive future, and career impact mirrors the findings of Neumann et al. (2024) who demonstrated significant mental health burden across 67 studies. Importantly, all treatments studied showed significant post-treatment improvement in mental health scores.")]),
  bullet([bold("Social/occupational domain: ", BURGUNDY), text("Role impairment (missing work during heavy cycle days) and dyspareunia causing sexual avoidance are consistent with SF-36 data showing fibroid-affected women rank in the lowest quartile for social functioning and role-physical sub-scores.")]),
  bullet([bold("Reproductive concerns: ", BURGUNDY), text("The FIGO Type 1 submucous fibroid is the most fertility-relevant finding. Evidence supports hysteroscopic resection before any IVF/natural conception attempt. The intramural fibroids are >5 cm, where impact on fertility is debated but warrants discussion.")]),
  spacer(),

  heading2("3.3  Decision-Making in This Patient"),
  para([text("Given: nulliparous, keen to preserve fertility, severe symptoms, multiple fibroids including FIGO Type 1 submucous:")]),
  twoColTable([
    ["Medical pre-treatment", "IV iron sucrose (correct severe anaemia pre-operatively); GnRH agonist (leuprolide) x 3 months — reduce fibroid volume, correct anaemia, improve surgical conditions; add-back HRT to prevent hypo-oestrogenic side effects"],
    ["Surgical plan", "Two-stage: Stage 1 - Hysteroscopic myomectomy for FIGO Type 1 submucous fibroid; Stage 2 - Laparoscopic myomectomy for dominant intramural fibroid(s)"],
    ["Alternative considered", "UAE deferred due to fertility wish (UAE associated with risk of ovarian reserve reduction and uterine synechiae)"],
    ["Post-operative follow-up", "TVS at 3 and 12 months; UFS-QoL repeat at 6 months; UFS-QoL improvement of ≥25 points = clinically meaningful response; fertility counselling; gynaecological follow-up annually"],
    ["Counselling regarding recurrence", "Fibroid recurrence after myomectomy: 11% if single fibroid removed; 26% if multiple fibroids removed (Berek & Novak's, p. 503)"]
  ], ["Aspect", "Plan"]),
  spacer(),

  heading2("3.4  Racial and Social Disparities"),
  para([text("Although this patient identifies as South Asian, it is essential to recognise that globally, Black women bear a disproportionate burden: earlier onset, more fibroids, larger tumours, more severe symptoms, and higher rates of surgical intervention "), bold("(Sabiston, p. 2960)", MID_GRAY), text(". Disparities in healthcare access, implicit bias in symptom minimisation, and socioeconomic barriers further delay diagnosis and treatment in marginalised populations. Gynaecology residents must be proactive in asking specifically about heavy bleeding, pelvic discomfort, and urinary symptoms in at-risk groups.")]),
  spacer(2)
];

// ─── CONCLUSION ───────────────────────────────────────────────────────────
const conclusionSection = [
  heading1("4. Key Learning Points for Gynaecology Residents"),
  bullet([bold("Fibroids affect up to 70% of women by age 50 ", BURGUNDY), text("— universal screening awareness is warranted in women of reproductive age presenting with AUB, pelvic pain, or urinary symptoms.")]),
  bullet([bold("The FIGO classification ", BURGUNDY), text("should be used routinely — it guides surgical approach and predicts symptom type (submucous = HMB; intramural/subserosal = bulk symptoms).")]),
  bullet([bold("Always use validated QoL tools ", BURGUNDY), text("(UFS-QoL, PBAC, SF-36) at baseline and follow-up. These objectify burden, guide intervention, and demonstrate treatment outcomes.")]),
  bullet([bold("Anaemia from HMB is under-treated ", BURGUNDY), text("— check Hb in all women with suspected fibroids; treat before surgery with oral/IV iron.")]),
  bullet([bold("Fertility implications ", BURGUNDY), text("must be proactively discussed: submucosal fibroids should be resected before ART; counsel regarding myomectomy recurrence rates.")]),
  bullet([bold("Mental health burden is real and significant ", BURGUNDY), text("— screen with validated tools; involve a multidisciplinary team including counselling where appropriate.")]),
  bullet([bold("All evidence-based treatments improve QoL ", BURGUNDY), text("— medical and surgical — supporting early intervention rather than watchful waiting in symptomatic women (Neumann et al., Fertil Steril 2024; 67 studies, 18 RCTs).")]),
  bullet([bold("Power morcellation is no longer standard of care ", BURGUNDY), text("in laparoscopic myomectomy/hysterectomy due to risk of disseminating occult uterine sarcoma.")]),
  bullet([bold("Racial disparities are clinically important ", BURGUNDY), text("— Black and South Asian women are at higher risk of more severe fibroid disease; avoid normalising their symptom reports.")]),
  spacer(2)
];

// ─── REFERENCES ───────────────────────────────────────────────────────────
const referencesSection = [
  heading1("5. References"),
  para([text("1.  Berek JS, Berek DL. Berek & Novak's Gynecology, 16th ed. Philadelphia: Wolters Kluwer; 2020. Chapter: Leiomyomata uteri and myomectomy, pp. 503-530.")]),
  para([text("2.  Townsend CM Jr, et al. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice, 21st ed. Philadelphia: Elsevier; 2022. Chapter 120: Gynaecology, pp. 2958-2977.")]),
  para([text("3.  Lockwood CJ, et al. Creasy & Resnik's Maternal-Fetal Medicine, 8th ed. Philadelphia: Elsevier; 2019. Chapter 28: Uterine myoma, pp. 624-625.")]),
  para([text("4.  Goldman L, Schafer AI. Goldman-Cecil Medicine, 27th ed. Philadelphia: Elsevier; 2023. Chapter on uterine fibroid treatment, p. 486.")]),
  para([text("5.  Kumar V, Abbas AK, Aster JC. Robbins, Cotran & Kumar Pathologic Basis of Disease, 10th ed. Philadelphia: Elsevier; 2021. Chapter 22: Leiomyoma, pp. 2058-2060.")]),
  para([text("6.  Neumann B, Singh B, Brennan J, Blanck J, Segars JH. The impact of fibroid treatments on quality of life and mental health: a systematic review. Fertil Steril. 2024;121(3):e1-e18. PMID: 38246400. DOI: 10.1016/j.fertnstert.2024.01.021")]),
  para([text("7.  Singh S, Kumar P, Kavita, et al. Contemporary approaches in the management of uterine leiomyomas. Eur J Obstet Gynecol Reprod Biol. 2023;287:55-68. PMID: 37385088.")]),
  para([text("8.  Gupta A, Balk EM, Lenger SM. Changes in Pelvic Floor Symptoms After Procedural Interventions for Uterine Leiomyomas: A Systematic Review. Obstet Gynecol. 2023;142(2):351-364. PMID: 37411023.")]),
  para([text("9.  Peng J, Wang J, Shu Q, et al. Systematic review and meta-analysis of current evidence in uterine artery embolization vs myomectomy for symptomatic uterine fibroids. Sci Rep. 2024;14:19353. PMID: 39164326.")]),
  para([text("10. Yan L, Huang H, Lin J. High-intensity focused ultrasound treatment for symptomatic uterine fibroids: a systematic review and meta-analysis. Int J Hyperthermia. 2022;39(1):98-109. PMID: 35094613.")]),
  para([text("11. Chen I, Berman JM, Balk EM, et al. Radiofrequency Ablation for the Treatment of Uterine Fibroids: A Systematic Review and Meta-Analysis by the AAGL Practice Committee. J Minim Invasive Gynecol. 2025;32(1):15-28. PMID: 39277104.")]),
  para([text("12. Puscasiu L, Vollenhoven B, Nagels HE. Preoperative medical therapy before surgery for uterine fibroids. Cochrane Database Syst Rev. 2025;4:CD010547. PMID: 40183418.")]),
  para([text("13. Schlaff WD, Ackerman RT, Al-Hendy A, et al. Elagolix for heavy menstrual bleeding in women with uterine fibroids. N Engl J Med. 2020;382:328-340.")]),
  para([text("14. Al-Hendy A, Lukes AS, Poindexter AN, et al. Treatment of uterine fibroid symptoms with relugolix combination therapy. N Engl J Med. 2021;384:630-642.")]),
  para([text("15. Manyonda I, Belli AM, Lumsden MA, et al. Uterine-artery embolization or myomectomy for uterine fibroids. N Engl J Med. 2020;383:440-451.")]),
  spacer()
];

// ─── APPENDIX: QoL Tools ──────────────────────────────────────────────────
const appendixSection = [
  heading1("Appendix: QoL Assessment Tools in Fibroid Practice"),
  twoColTable([
    ["UFS-QoL", "Uterine Fibroid Symptom and Quality of Life questionnaire. 37-item fibroid-specific tool. Symptom Severity Score (0-100; higher = worse) + Health-Related Quality of Life (HRQoL) subscale (0-100; higher = better). Most widely validated tool for fibroid clinical trials."],
    ["PBAC", "Pictorial Blood Assessment Chart. Scores sanitary pad/tampon usage and clot passage. Score >100 = clinically significant HMB. Objective, patient-completed, correlates with measured blood loss."],
    ["SF-36", "Short Form-36 Health Survey. Generic 36-item tool measuring 8 health domains. Enables comparison of fibroid patients with other chronic conditions. Fibroid patients score lower than women with hypertension, cardiac disease, or COPD."],
    ["NRS/VAS Pain", "Numerical Rating Scale or Visual Analogue Scale for dysmenorrhoea, non-cyclic pain, dyspareunia. Simple, validated, reproducible."],
    ["EQ-5D", "EuroQoL 5-Dimension tool. Used for health economic analysis. Converts health states to utility scores for cost-effectiveness modelling."],
    ["PHQ-9 / GAD-7", "Depression and anxiety screening. Important adjuncts given the documented mental health burden in fibroid-affected women (Neumann et al., 2024)."]
  ], ["Tool", "Description & Clinical Use"])
];

// ─── Assemble Document ────────────────────────────────────────────────────
const doc = new Document({
  numbering: {
    config: [
      {
        reference: "bullet-list",
        levels: [
          {
            level: 0,
            format: LevelFormat.BULLET,
            text: "\u2022",
            alignment: AlignmentType.LEFT,
            style: {
              paragraph: {
                indent: { left: convertInchesToTwip(0.5), hanging: convertInchesToTwip(0.25) }
              }
            }
          },
          {
            level: 1,
            format: LevelFormat.BULLET,
            text: "\u25E6",
            alignment: AlignmentType.LEFT,
            style: {
              paragraph: {
                indent: { left: convertInchesToTwip(1.0), hanging: convertInchesToTwip(0.25) }
              }
            }
          }
        ]
      }
    ]
  },
  styles: {
    default: {
      document: {
        run: { font: "Calibri", size: 22, color: DARK_GRAY }
      }
    },
    paragraphStyles: [
      {
        id: "Heading1",
        name: "Heading 1",
        basedOn: "Normal",
        next: "Normal",
        run: {
          font: "Calibri",
          size: 32,
          bold: true,
          color: BURGUNDY,
          allCaps: true
        },
        paragraph: {
          spacing: { before: 400, after: 160 }
        }
      },
      {
        id: "Heading2",
        name: "Heading 2",
        basedOn: "Normal",
        next: "Normal",
        run: {
          font: "Calibri",
          size: 26,
          bold: true,
          color: LIGHT_BURGUNDY
        },
        paragraph: {
          spacing: { before: 280, after: 80 }
        }
      },
      {
        id: "Heading3",
        name: "Heading 3",
        basedOn: "Normal",
        next: "Normal",
        run: {
          font: "Calibri",
          size: 23,
          bold: true,
          italics: true,
          color: DARK_GRAY
        },
        paragraph: {
          spacing: { before: 160, after: 60 }
        }
      }
    ]
  },
  sections: [
    {
      properties: {
        page: {
          margin: {
            top: convertInchesToTwip(1.0),
            bottom: convertInchesToTwip(1.0),
            left: convertInchesToTwip(1.2),
            right: convertInchesToTwip(1.2)
          }
        }
      },
      headers: {
        default: new Header({
          children: [
            new Paragraph({
              children: [
                new TextRun({ text: "Case Paper: Uterine Fibroids | QoL Impact | Gynaecology Residency", font: "Calibri", size: 18, italics: true, color: MID_GRAY }),
                new TextRun({ children: [new PageNumber()], font: "Calibri", size: 18, color: MID_GRAY })
              ],
              border: { bottom: { style: BorderStyle.SINGLE, size: 2, color: BURGUNDY, space: 4 } },
              alignment: AlignmentType.RIGHT
            })
          ]
        })
      },
      children: [
        titleBlock,
        spacer(2),
        ...abstractSection,
        ...caseSection,
        ...literatureSection,
        ...discussionSection,
        ...conclusionSection,
        ...referencesSection,
        ...appendixSection
      ]
    }
  ]
});

Packer.toBuffer(doc).then(buffer => {
  fs.writeFileSync("/home/daytona/workspace/fibroid-case-presentation/Uterine_Fibroid_Case_Paper_Gynec_Residency.docx", buffer);
  console.log("SUCCESS: Document created.");
}).catch(err => {
  console.error("ERROR:", err);
  process.exit(1);
});

Error: String not found in file: '        headers: {
        default: new Header({
          children: [
            new Paragraph({
              children: [
                new TextRun({ text: "Case Paper: Uterine Fibroids | QoL Impact | Gynaecology Residency", font: "Calibri", size: 18, italics: true, color: MID_GRAY }),
                new TextRun({ children: [new PageNumber()], font: "Calibri", size: 18, color: MID_GRAY })
              ],
              border: { bottom: { style: BorderStyle.SINGLE, size: 2, color: BURGUNDY, space: 4 } },
              alignment: AlignmentType.RIGHT
            })
          ]
        })
      },'

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/fibroid-case-presentation/create_fibroid_case.js'