Approach to Acute Liver Failure in Children: A Case-Based Scenario

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

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// ═══════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ═══════════════════════════════════════════════════════════════════
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 2 — CASE INTRODUCTION
// ═══════════════════════════════════════════════════════════════════
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    { text: "Deeply jaundiced  •  GCS 12/15 (disoriented)  •  Febrile 38.6°C  •  HR 118  •  BP 90/60\nLiver NOT palpable (shrunken)  •  Bilateral Babinski positive", options: { fontSize: 13, color: C.darkTxt } }
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 3 — CASE LABS
// ═══════════════════════════════════════════════════════════════════
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    ["AST / ALT", "4200 / 3800 U/L", "Massive hepatocellular necrosis"],
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    [{ text: "INR / PT", options: { bold: true } }, { text: "3.8 / 38 sec", options: { bold: true, color: C.red } }, { text: "Synthetic failure — KEY criterion", options: { bold: true, color: C.red } }],
    ["Serum Ammonia", "210 µmol/L", "Risk of cerebral edema / herniation"],
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 4 — SECTION DIVIDER: DEFINITION
// ═══════════════════════════════════════════════════════════════════
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 5 — DEFINITION OF PALF
// ═══════════════════════════════════════════════════════════════════
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 6 — EPIDEMIOLOGY & PROGNOSIS
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    ["Historical mortality (pre-transplant era)", "70 – 95%"],
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    ["Post-transplant 1-year patient survival (PALF)", "73%"],
    ["Post-transplant 1-year graft survival (PALF)", "59%"],
    ["PALF listing rate (2020)", "7.7% (most recover with medical Rx)"],
    ["Etiology indeterminate (pediatric)", "~50% (vs 15% in adults)"],
    ["Cerebral edema in Grade 4 encephalopathy", "~80% of patients"],
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 7 — SECTION DIVIDER: ETIOLOGY
// ═══════════════════════════════════════════════════════════════════
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 8 — ETIOLOGY MNEMONIC
// ═══════════════════════════════════════════════════════════════════
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    { l: "C", c: C.teal,  t: "Hepatitis C  •  Cryptogenic" },
    { l: "D", c: C.navy,  t: "Drugs / Toxins (idiosyncratic DILI)  •  Hepatitis D" },
    { l: "E", c: C.teal,  t: "Hepatitis E  •  Esoteric causes (Wilson disease, Budd-Chiari, lymphoma)" },
    { l: "F", c: C.amber, t: "Fatty change – microvesicular (Reye syndrome, valproate, tetracycline)" },
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 9 — PEDIATRIC-SPECIFIC CAUSES
// ═══════════════════════════════════════════════════════════════════
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    ["Neonates / Infants", "Galactosemia, Hereditary fructose intolerance, Tyrosinemia type 1, HSV, Neonatal hemochromatosis"],
    ["Toddlers (1–5 yr)", "Mitochondrial disorders (POLG), Metabolic disease, Viral (EBV, adenovirus), HLH"],
    ["School-age (5–12 yr)", "Wilson disease ★, Autoimmune hepatitis, Viral hepatitis (A, B, E)"],
    ["Adolescents", "Acetaminophen (intentional overdose), Autoimmune hepatitis, Wilson disease, Viral"],
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 10 — DIAGNOSTIC WORKUP PANEL
// ═══════════════════════════════════════════════════════════════════
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    "VIRAL PCR: EBV, CMV, HSV, Adenovirus (esp. if immunocompromised)",
    "METABOLIC: Ceruloplasmin, 24h urine copper, slit-lamp exam (Wilson)",
    "METABOLIC: Plasma amino acids, urine organic acids, lactate/pyruvate",
    "AUTOIMMUNE: ANA, ASMA, anti-LKM1, serum IgG",
  ];
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    "TOXICOLOGY: Acetaminophen level, paracetamol screen, salicylates",
    "SEPSIS: Blood cultures x2, urine culture, CRP, procalcitonin",
    "HLH screen: Ferritin, triglycerides, NK cell activity, sCD25",
    "HAEMATOLOGY: CBC, peripheral smear, bone marrow biopsy if HLH",
    "IMAGING: Liver USS with Doppler (vascular), CXR, ECHO if needed",
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 11 — SECTION DIVIDER: IMMEDIATE MANAGEMENT
// ═══════════════════════════════════════════════════════════════════
{
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  sectionDivider(s, "03", "Immediate Stabilization", "First hours determine outcome");
  footer(s, 11);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 12 — IMMEDIATE STEPS (ABCs + TRANSFER)
// ═══════════════════════════════════════════════════════════════════
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    { num: "2", title: "Correct Hypoglycemia NOW", body: "D10W infusion  •  Target glucose > 70 mg/dL  •  Check every 1–2 hours" },
    { num: "3", title: "Haemodynamic Support", body: "Normal saline bolus 10 mL/kg for hypotension  •  Add Norepinephrine if no response  •  Target MAP ≥ 60 mmHg" },
    { num: "4", title: "TRANSFER to Liver Transplant Centre", body: '"Patients with ALF should be immediately transferred — this can progress rapidly to fulminant failure and death" — Current Surgical Therapy 14e' },
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// ═══════════════════════════════════════════════════════════════════
// SLIDE 13 — METABOLIC EMERGENCY TABLE
// ═══════════════════════════════════════════════════════════════════
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     { text: "Intervention", options: { bold: true, color: C.white, fill: { color: C.navy } } }],
    [{ text: "Hypoglycaemia", options: { bold: true, color: C.red } }, "> 70 mg/dL", "D10W continuous infusion; check q1h"],
    ["Coagulopathy (INR 3.8)", "Monitor trend only", "Vitamin K IV (up to 10 mg); FFP ONLY for active bleeding/procedure"],
    [{ text: "Hyperammonaemia", options: { bold: true } }, "Reduce < 100 µmol/L", "Restrict protein temporarily; lactulose (limited ALF evidence); RRT if needed"],
    ["Metabolic acidosis (pH 7.31)", "pH > 7.35", "Cautious fluid; identify source; bicarbonate rarely needed"],
    ["Hyponatraemia", "Na 145–155 mEq/L", "Restrict free water; hypertonic saline for ICP control"],
    [{ text: "Hypotension (BP 90/60)", options: { bold: true, color: C.red } }, "MAP ≥ 60 mmHg", "NS 10 mL/kg bolus → norepinephrine → vasopressin"],
  ];

  s.addTable(rows, {
    x: 0.25, y: 1.3, w: 9.5, h: 3.9,
    border: { pt: 1, color: "CCDDEC" },
    colW: [2.5, 2.2, 4.8],
  });

  footer(s, 13);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 14 — IMPORTANT CAVEAT: COAGULOPATHY & LACTULOSE
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "Two Critical Misconceptions in PALF Management", "Current Surgical Therapy 14e  •  Goldman-Cecil Medicine");

  // Box 1
  s.addShape(pres.shapes.RECTANGLE, { x: 0.25, y: 1.25, w: 9.5, h: 1.8, fill: { color: "FDECEA" }, line: { color: C.red, pt: 2 } });
  s.addText([
    { text: "MISCONCEPTION 1: Correct the INR with FFP\n", options: { bold: true, fontSize: 15, color: C.red, breakLine: true } },
    { text: "INR in ALF does NOT reflect true bleeding risk — clotting inhibitors (Protein C & S) are also lost, creating a re-balanced haemostasis.\n", options: { fontSize: 13, color: C.darkTxt, breakLine: true } },
    { text: "Giving FFP masks the INR trend, which is your MOST important prognostic marker. Give FFP only for active bleeding or before invasive procedures.", options: { fontSize: 12, color: C.darkTxt, italic: true } }
  ], { x: 0.4, y: 1.3, w: 9.1, h: 1.65, valign: "top", margin: 0 });

  // Box 2
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  s.addText([
    { text: "MISCONCEPTION 2: Use Lactulose for encephalopathy (as in cirrhosis)\n", options: { bold: true, fontSize: 15, color: C.amber, breakLine: true } },
    { text: "ALF encephalopathy is driven by CEREBRAL OEDEMA — not portosystemic shunting.\n", options: { fontSize: 13, color: C.darkTxt, breakLine: true } },
    { text: "Lactulose has NEVER been shown to improve survival in ALF. Therapeutic focus must be on ICP reduction (head elevation, mannitol, hypertonic saline, sedation).", options: { fontSize: 12, color: C.darkTxt, italic: true } }
  ], { x: 0.4, y: 3.25, w: 9.1, h: 1.65, valign: "top", margin: 0 });

  footer(s, 14);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 15 — SECTION DIVIDER: COMPLICATIONS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "04", "Complications", "The killers — recognise and manage proactively");
  footer(s, 15);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 16 — CEREBRAL OEDEMA (THE #1 KILLER)
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "Cerebral Oedema — The Leading Cause of Death in PALF", "Current Surgical Therapy 14e");

  infoBox(s, "PATHOPHYSIOLOGY",
    "Hyperammonaemia → Cerebral astrocyte swelling (glutamine accumulation) → Cytotoxic oedema → ↑ICP → ↓CPP → Ischaemia + Herniation",
    0.25, 1.3, 9.5, 0.9, "FFF2CC", C.amber);

  s.addText("Management Protocol", { x: 0.25, y: 2.35, w: 9.5, h: 0.4, fontSize: 14, bold: true, color: C.navy, margin: 0 });

  const mgmt = [
    "Head of bed at 30° at all times",
    "Intubate early (Grade 3 encephalopathy) — controlled ventilation, target PaCO2 35-40 mmHg",
    "Minimize stimulation; sedation/neuromuscular blockade (reduces ICP spikes)",
    "Mannitol 0.5–1 g/kg IV bolus for ICP spikes (only if serum osmolality < 320 mOsm/L)",
    "Hypertonic saline (3%) to target serum Na 145–155 mEq/L — prophylactic osmotherapy",
    "ICP monitoring (invasive) in Grade 3–4 encephalopathy — consider at transplant centre",
    "Avoid hyperthermia, hypoxia, hypotension — all worsen oedema",
    "CT brain: insensitive early, but rules out intracranial haemorrhage",
  ];
  bullets(s, mgmt, { y: 2.75, h: 2.35, fs: 12 });

  warningBox(s, "Ammonia > 150–200 µmol/L correlates with risk of cerebral herniation — act aggressively", 0.25, 5.08, 9.5);
  footer(s, 16);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 17 — OTHER MAJOR COMPLICATIONS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "Other Major Complications in PALF", "Anticipate and monitor for all simultaneously");

  const comps = [
    { title: "Hepatorenal Syndrome", body: "Avoid nephrotoxins (NSAIDs, aminoglycosides, contrast)  •  Strict I/O monitoring  •  CVVH for oliguria/AKI" },
    { title: "Sepsis & Infection", body: "Gram-positive cocci + Candida most common  •  Low threshold for blood/urine cultures  •  Empirical broad-spectrum antibiotics + antifungals" },
    { title: "GI Bleeding", body: "PPIs / H2 blockers for prophylaxis  •  FFP + platelets if actively bleeding  •  Avoid NG tubes unless needed" },
    { title: "Hypoglycaemia", body: "Continuous D10W infusion  •  Check glucose every 1–2 hours  •  Glucagon NOT effective in liver failure" },
    { title: "Pulmonary Complications", body: "Risk of pulmonary oedema (↑capillary permeability + fluid overload)  •  ARDS  •  Early intubation protective" },
    { title: "Multi-organ Failure", body: "Reflects disease severity  •  Prognostic significance  •  Activate transplant listing without delay" },
  ];

  comps.forEach((c, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = col === 0 ? 0.25 : 5.15;
    const y = 1.3 + row * 1.38;
    s.addShape(pres.shapes.RECTANGLE, { x, y, w: 4.75, h: 1.25, fill: { color: i % 2 === 0 ? "EDF4F8" : "F4FBFD" }, line: { color: "C0D6E8" } });
    s.addText([
      { text: c.title + "\n", options: { bold: true, fontSize: 12, color: C.teal, breakLine: true } },
      { text: c.body, options: { fontSize: 11, color: C.darkTxt } }
    ], { x: x + 0.12, y: y + 0.06, w: 4.5, h: 1.1, valign: "top", margin: 0 });
  });

  footer(s, 17);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 18 — SECTION DIVIDER: PROGNOSIS & TRANSPLANT
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "05", "Prognostic Criteria & Transplant", "When to list — the hardest decision");
  footer(s, 18);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 19 — KING'S COLLEGE CRITERIA
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "King's College Criteria — When to List for Transplant", "Current Surgical Therapy 14e  |  PPV 80–100%");

  // Acetaminophen box
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  s.addText("ACETAMINOPHEN-INDUCED", { x: 0.35, y: 1.35, w: 4.3, h: 0.4, fontSize: 12, bold: true, color: C.teal, margin: 0 });
  s.addText([
    { text: "pH < 7.3\n", options: { bold: true, fontSize: 14, color: C.red, breakLine: true } },
    { text: "OR\n", options: { fontSize: 12, color: C.darkTxt, breakLine: true } },
    { text: "INR > 6.5  AND  Creatinine > 3.4 mg/dL", options: { fontSize: 13, bold: true, color: C.red } }
  ], { x: 0.4, y: 1.8, w: 4.2, h: 1.5, valign: "middle", margin: 0 });

  // Non-acetaminophen box
  s.addShape(pres.shapes.RECTANGLE, { x: 5.2, y: 1.3, w: 4.55, h: 2.2, fill: { color: "FFF8EC" }, line: { color: C.amber, pt: 2 } });
  s.addText("NON-ACETAMINOPHEN", { x: 5.3, y: 1.35, w: 4.3, h: 0.4, fontSize: 12, bold: true, color: C.amber, margin: 0 });
  s.addText([
    { text: "INR > 6.5  alone  OR  any 3 of:\n", options: { bold: true, fontSize: 12, color: C.red, breakLine: true } },
    { text: "• INR > 3.5\n• Bilirubin > 17.6 mg/dL\n• Age < 10 or > 40 years\n• Drug toxicity as cause\n• Jaundice-to-encephalopathy > 7 days", options: { fontSize: 12, color: C.darkTxt } }
  ], { x: 5.3, y: 1.78, w: 4.2, h: 1.6, valign: "top", margin: 0 });

  // Case application
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  s.addText([
    { text: "OUR CASE MEETS CRITERIA:\n", options: { bold: true, fontSize: 13, color: C.red, breakLine: true } },
    { text: "Age 9 (< 10 years)  +  Bilirubin 18 mg/dL (> 17.6)  +  INR 3.8 (> 3.5)  =  3 criteria  →  LIST FOR TRANSPLANT", options: { fontSize: 13, color: C.darkTxt, bold: true } }
  ], { x: 0.4, y: 3.7, w: 9.1, h: 0.9, valign: "middle", margin: 0 });

  infoBox(s, "NOTE", "Serial monitoring every 6–12h. Improvement in INR/Factor V = regeneration = may avoid transplant", 0.25, 4.85, 9.5, 0.5, "E8F4FD", C.teal);

  footer(s, 19);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 20 — SERIAL BIOMARKERS FOR PROGNOSIS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "Serial Biomarkers for Prognosis — Monitor Every 6–12h", "Goldman-Cecil Medicine");

  const rows = [
    [{ text: "Biomarker", options: { bold: true, color: C.white, fill: { color: C.navy } } },
     { text: "Trend suggesting Recovery", options: { bold: true, color: C.white, fill: { color: C.navy } } },
     { text: "Trend suggesting Need for Transplant", options: { bold: true, color: C.white, fill: { color: C.navy } } }],
    [{ text: "INR / Factor V ★", options: { bold: true } }, "Falling INR = synthetic recovery", "Rising INR = progressive failure"],
    ["Serum Bilirubin", "Plateau or fall", "Continuously rising = poor"],
    ["Arterial Ammonia", "< 100 µmol/L, falling", "> 150–200 µmol/L → herniation risk"],
    ["Serum pH", "Normalising > 7.35", "Persistent acidosis < 7.3 = listing criteria"],
    ["Lactate", "Falling < 2 mmol/L", "Persistent ↑ = multi-organ failure"],
    ["Creatinine", "Stable or falling", "Rising = HRS → worse prognosis"],
  ];

  s.addTable(rows, {
    x: 0.25, y: 1.3, w: 9.5, h: 3.9,
    border: { pt: 1, color: "CCDDEC" },
    colW: [2.4, 3.5, 3.6],
  });

  s.addText("★ Factor V has the shortest half-life of all clotting factors — it is the MOST sensitive marker of hepatic regeneration vs. deterioration", {
    x: 0.25, y: 5.1, w: 9.5, h: 0.35, fontSize: 10, color: C.teal, italic: true, margin: 0
  });

  footer(s, 20);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 21 — SECTION DIVIDER: SPECIFIC THERAPIES
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "06", "Etiology-Directed Therapy", "Treat the cause, not just the failure");
  footer(s, 21);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 22 — SPECIFIC THERAPIES TABLE
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "Specific / Etiology-Directed Treatments", "Identify the cause → targeted therapy changes outcomes");

  const rows = [
    [{ text: "Etiology", options: { bold: true, color: C.white, fill: { color: C.navy } } },
     { text: "Specific Treatment", options: { bold: true, color: C.white, fill: { color: C.navy } } }],
    [{ text: "Acetaminophen toxicity", options: { bold: true } }, "N-Acetylcysteine (NAC) IV: 150 mg/kg/h × 1h → 50 mg/kg/4h → 100 mg/kg/16h. Continue beyond standard protocol in ALF."],
    ["Autoimmune hepatitis", "IV Methylprednisolone 1–2 mg/kg/day (controversial in ALF; consult hepatology urgently)"],
    [{ text: "Wilson disease ★", options: { bold: true, color: C.teal } }, "D-penicillamine + zinc supplementation; plasmapheresis as bridge to transplant; LT is CURATIVE"],
    ["Herpes simplex hepatitis", "IV Acyclovir 15–30 mg/kg/day (empirical if HSV suspected — high mortality if delayed)"],
    ["HLH", "Dexamethasone + Etoposide (HLH-2004 protocol); consider HSCT"],
    ["Amanita phalloides poisoning", "Silibinin (milk thistle) IV + NAC + early LT listing"],
    ["Galactosaemia / Fructosaemia", "Remove galactose/fructose from diet IMMEDIATELY"],
  ];

  s.addTable(rows, {
    x: 0.25, y: 1.3, w: 9.5, h: 3.9,
    border: { pt: 1, color: "CCDDEC" },
    colW: [2.8, 6.7],
  });

  s.addText("★ Our case — Wilson disease: diagnosed by low ceruloplasmin + high urine copper + Kayser-Fleischer rings", {
    x: 0.25, y: 5.1, w: 9.5, h: 0.35, fontSize: 10, color: C.teal, italic: true, margin: 0
  });

  footer(s, 22);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 23 — LIVER TRANSPLANT IN PALF
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "Liver Transplantation in PALF", "Fischer's Mastery of Surgery 8e  •  Current Surgical Therapy 14e");

  const left = [
    "ONLY definitive treatment for ALF meeting criteria",
    "Without transplant: mortality ~80% in fulminant ALF",
    "Options: whole-organ, living-donor split, or APOLT (auxiliary — allows native liver regeneration)",
    "1-year patient survival post-LT for PALF: 73%",
    "1-year graft survival post-LT for PALF: 59%",
    "(vs 89% / 78% for biliary atresia — lower outcomes reflect disease severity)",
  ];
  const right = [
    "Listing rate decreased to 7.7% in 2020 — most children recover",
    "List early — do not wait for Grade 4 encephalopathy",
    "Discuss with family: lifelong immunosuppression vs. mortality risk",
    "Post-LT monitoring: rejection, infection, metabolic complications",
    "Wilson disease: LT is curative — copper metabolism normalises",
    "Genetic diagnoses (POLG, tyrosinaemia): LT not always curative",
  ];

  twoCol(s, left, right, { yStart: 1.3, fs: 12 });

  footer(s, 23);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 24 — CASE CONCLUSION + MANAGEMENT ALGORITHM
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleBar(s, "Case Conclusion & Management Algorithm", "Tying it all together");

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  s.addText([
    { text: "Case Outcome:\n", options: { bold: true, fontSize: 13, color: C.teal, breakLine: true } },
    { text: "Intubated for Grade 3–4 encephalopathy  •  Transferred to PICU of transplant centre  •  Wilson disease confirmed (low ceruloplasmin, high urine copper, KF rings)  •  Plasmapheresis as bridge  •  Living-donor LT from parent on Day 7  •  Post-LT: tackled rejection with pulse steroids  •  Discharged Day 28 on tacrolimus  •  Full recovery — Wilson disease cured", options: { fontSize: 11, color: C.darkTxt } }
  ], { x: 0.4, y: 1.3, w: 9.1, h: 1.35, valign: "top", margin: 0 });

  // Algorithm
  const steps = [
    "Jaundice + Coagulopathy + Altered Sensorium → CONFIRM PALF",
    "Stabilise (ABC, glucose, ICP control) + URGENT TRANSFER",
    "Parallel: Etiology workup (ABCDEF) + Monitor complications",
    "Apply King's College Criteria (serial INR, Factor V q6h)",
    "Etiology-directed therapy (NAC / steroids / copper chelation etc.)",
    "TRANSPLANT if criteria met or clinical deterioration",
  ];

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  footer(s, 24);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 25 — SUMMARY & REFERENCES
// ═══════════════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  s.background = { color: C.navy };
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.teal }, line: { color: C.teal } });
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  const msgs = [
    "PALF = severe hepatic dysfunction < 8 weeks + coagulopathy (INR ≥1.5 with, ≥2.0 without encephalopathy). Encephalopathy NOT mandatory in children.",
    "TRANSFER immediately to a liver transplant centre — delay is the enemy.",
    "Correct hypoglycaemia aggressively. Do NOT reflexively correct INR with FFP — it masks prognosis.",
    "Cerebral oedema is the #1 killer. Mannitol, hypertonic saline, controlled ventilation, and ICP monitoring are essential.",
    "Lactulose has no survival benefit in ALF (different mechanism from cirrhosis).",
    "ABCDEF mnemonic for causes. In ~50% of children, cause is never found.",
    "King's College Criteria: PPV 80–100%. Apply and list for transplant without hesitation when met.",
    "Serial Factor V / INR every 6–12h is the best indicator of regeneration vs. deterioration.",
    "Etiology-directed therapy is critical (NAC for APAP, acyclovir for HSV, LT for Wilson disease).",
  ];

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  });

  s.addText("References: Fischer's Mastery of Surgery 8e  •  Goldman-Cecil Medicine  •  Robbins, Cotran & Kumar Pathologic Basis of Disease  •  Current Surgical Therapy 14e  •  PMID 38700362, 41159810 (2024–25)", {
    x: 0.45, y: 5.3, w: 9.3, h: 0.28, fontSize: 8, color: "4A6A8A", margin: 0
  });
}

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