"acute pancreatitis"[MeSH Terms] AND management

mkdir -p /home/daytona/workspace/acute-pancreatitis-pptx && ls /home/daytona/wor…

~/acute-pancreatitis-pptx/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE";
pres.title = "Acute Pancreatitis: Diagnosis, Management & Treatment";
pres.author = "Postgraduate Medical Education";

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// ═══════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════
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  s.addText("ACUTE PANCREATITIS", { x: 0.5, y: 1.3, w: 9, h: 1.1, fontSize: 46, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 4 });
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  s.addText("Sources: Goldman-Cecil Medicine | Sleisenger & Fordtran | Robbins & Kumar | Rosen's Emergency Medicine", { x: 0.5, y: 6.8, w: 12.3, h: 0.3, fontSize: 10, color: C.gray, fontFace: "Calibri", italic: true });
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// ═══════════════════════════════════════════════════════════════
// SLIDE 2 — AGENDA
// ═══════════════════════════════════════════════════════════════
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  const topics = [
    ["01", "Definition & Epidemiology"],
    ["02", "Etiology & Risk Factors"],
    ["03", "Pathogenesis"],
    ["04", "Clinical Features & Diagnosis"],
    ["05", "Severity Scoring & Atlanta Classification"],
    ["06", "Imaging"],
    ["07", "Management — Initial Resuscitation"],
    ["08", "Nutrition & Pharmacotherapy"],
    ["09", "Complications & Interventions"],
    ["10", "Special Scenarios & Follow-Up"],
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// ═══════════════════════════════════════════════════════════════
// SECTION 1 — DEFINITION & EPIDEMIOLOGY
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 1", "Definition & Epidemiology");

{
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  slideTitle(s, pres, "Definition of Acute Pancreatitis", "Revised Atlanta Classification 2012");
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    { text: "DIAGNOSIS REQUIRES 2 OF 3 CRITERIA:", options: { bold: true, fontSize: 13, color: C.teal, breakLine: true } },
    { text: "1. Acute onset of epigastric pain (often radiating to the back)", options: { fontSize: 15, color: C.white, breakLine: true } },
    { text: "2. Serum amylase or lipase > 3× upper limit of normal", options: { fontSize: 15, color: C.white, breakLine: true } },
    { text: "3. Characteristic findings on cross-sectional imaging (CT/MRI)", options: { fontSize: 15, color: C.white } },
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  // stat boxes
  const stats = [
    { n: "40", unit: "per 100,000", label: "Annual Incidence (USA)" },
    { n: "300K", unit: "admissions/yr", label: "US Hospitalizations" },
    { n: "5%", unit: "overall mortality", label: "Mild-Moderate AP" },
    { n: "30%", unit: "mortality", label: "Severe Necrotizing AP" },
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}

// ═══════════════════════════════════════════════════════════════
// SECTION 2 — ETIOLOGY
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 2", "Etiology & Risk Factors");

{
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  slideTitle(s, pres, "Etiology of Acute Pancreatitis", "Gallstones + Alcohol = ~80% of cases");

  // Two main causes
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  s.addText([
    { text: "• Small stones (≤5 mm) pass cystic duct and reach ampulla\n", options: { fontSize: 13, color: C.white } },
    { text: "• Transient obstruction at ampulla of Vater\n", options: { fontSize: 13, color: C.white } },
    { text: "• Microlithiasis/biliary sludge underdiagnosed\n", options: { fontSize: 13, color: C.white } },
    { text: "• Only 5% of gallstone patients develop pancreatitis", options: { fontSize: 13, color: C.white } },
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  s.addText([
    { text: "• >5 years of heavy use (≥5–8 drinks/day) usually required\n", options: { fontSize: 13, color: C.white } },
    { text: "• Most already have underlying chronic pancreatitis\n", options: { fontSize: 13, color: C.white } },
    { text: "• Cofactors: high-fat diet, smoking, genetic variability\n", options: { fontSize: 13, color: C.white } },
    { text: "• Smoking is the strongest cofactor", options: { fontSize: 13, color: C.white } },
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  const others = [
    ["METABOLIC", "Hypertriglyceridemia (>1000 mg/dL)\nHyperparathyroidism / Hypercalcemia"],
    ["DRUGS", "Azathioprine, valproate, thiazides\nEstrogens, L-asparaginase, steroids"],
    ["MECHANICAL", "Trauma, post-ERCP (2–5%)\nPancreas divisum, periampullary tumors"],
    ["INFECTIOUS", "Mumps, coxsackievirus\nAscaris lumbricoides, Clonorchis sinensis"],
  ];
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  s.addText("Idiopathic: 10-20% — many have occult microlithiasis or genetic mutations (PRSS1, SPINK1, CFTR)", { x: 0.5, y: 7.05, w: 12.3, h: 0.3, fontSize: 11, color: C.gray, fontFace: "Calibri", italic: true });
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// ═══════════════════════════════════════════════════════════════
// SECTION 3 — PATHOGENESIS
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 3", "Pathogenesis");

{
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  slideTitle(s, pres, "Pathogenesis of Acute Pancreatitis", "Premature enzyme activation is the central event");

  // Central concept box
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  // Three pathways
  const pathways = [
    { title: "1. DUCTAL OBSTRUCTION", color: C.amber, x: 0.4,
      steps: ["Gallstone impaction at ampulla", "↑ Intraductal pressure", "Lipase (active) → Fat necrosis", "Leukocytes release cytokines → Edema", "Edema → Vascular insufficiency → Ischemia"] },
    { title: "2. PRIMARY ACINAR INJURY", color: C.teal, x: 4.65,
      steps: ["Alcohol, hypertriglyceridemia, ischemia, drugs, trauma", "Triglyceride hydrolysis → Toxic free fatty acids", "Intracellular Ca²⁺ rise", "Trypsinogen activation", "Cascade of digestive enzyme activation"] },
    { title: "3. DEFECTIVE TRANSPORT", color: C.red, x: 8.9,
      steps: ["Proenzymes + lysosomal hydrolases co-packaged", "Lysosomal rupture (phospholipases)", "Intracellular zymogen activation", "Local release of activated enzymes", "Cell necrosis and inflammation"] },
  ];
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  // SIRS note
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  s.addText("Systemic spillover of cytokines + activated enzymes → SIRS → Organ failure (lung, kidney, cardiovascular)", { x: 0.5, y: 7.12, w: 12.2, h: 0.28, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
}

// ═══════════════════════════════════════════════════════════════
// SECTION 4 — CLINICAL FEATURES & DIAGNOSIS
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 4", "Clinical Features & Diagnosis");

{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Clinical Presentation", "Symptoms correlate poorly with severity");

  bulletBox(s, pres, [
    "## SYMPTOMS",
    "Persistent epigastric or LUQ pain — sudden onset, moderate-to-severe",
    "  Radiation to back, chest, or flanks (\"band-like\")",
    "  Pain relieved by sitting forward / bending (partial)",
    "Nausea, vomiting, anorexia — oral intake worsens pain",
    "## SIGNS",
    "Fever, tachycardia (pain / inflammation)",
    "  Severe/complicated: Hypotension, signs of shock",
    "Jaundice → suggests biliary obstruction",
    "Abdominal tenderness ± guarding ± rigidity (peritoneal irritation)",
    "  Cullen's sign (periumbilical bruising) — hemorrhagic pancreatitis",
    "  Grey Turner's sign (flank bruising) — hemorrhagic pancreatitis",
    "Decreased breath sounds — pleural effusion / splinting",
    "## LABS",
    "Lipase: more specific and sensitive than amylase (preferred biomarker)",
    "  Lipase remains elevated longer (days); amylase normalizes in 24–72 h",
    "CBC (leukocytosis), BMP (BUN, Cr, glucose), LFTs (ALP, ALT > 3x → biliary)",
    "CRP > 150 mg/L at 48 h → predictor of severe disease",
    "Hematocrit > 44% (hemoconcentration) → marker of severity",
  ], { fontSize: 14.5 });
}

// Diagnosis Algorithm
{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Diagnostic Workup Algorithm");

  const steps = [
    { label: "HISTORY & EXAM", detail: "Pain character, alcohol, medications, prior attacks, family history, gallstone risk" },
    { label: "LABS", detail: "Lipase (≥3× ULN confirms), Amylase, LFTs, CBC, BMP, Triglycerides, Ca²⁺, CRP" },
    { label: "ABDOMINAL ULTRASOUND", detail: "1st line — gallstones, CBD dilation, biliary sludge. Limited by bowel gas/obesity." },
    { label: "CECT ABDOMEN", detail: "Gold standard for necrosis, peripancreatic collections, complications. Perform if diagnosis unclear or severe disease. Best at 48–72 h." },
    { label: "MRI/MRCP", detail: "If CT contraindicated. Superior for stones, ductal anatomy, suspected malignancy." },
    { label: "EUS / ERCP", detail: "EUS: detect microlithiasis, occult malignancy. ERCP: therapeutic only (no diagnostic role)." },
  ];

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// ═══════════════════════════════════════════════════════════════
// SECTION 5 — SEVERITY SCORING
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 5", "Severity Scoring & Atlanta Classification");

{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Revised Atlanta Classification 2012", "Three severity grades based on organ failure and complications");

  const grades = [
    { grade: "MILD AP", color: "2ECC71", bgColor: "0A2E1C",
      points: ["No organ failure", "No local or systemic complications", "Usually resolves within 1 week", "Mortality: < 1%", "Management: supportive outpatient/short inpatient"] },
    { grade: "MODERATELY SEVERE AP", color: C.amber, bgColor: "2D200A",
      points: ["Transient organ failure (resolves < 48 h)", "OR local complications (APFC, ANC, pseudocyst, WON)", "OR exacerbation of pre-existing co-morbidities", "Mortality: ~8%", "May need ICU monitoring"] },
    { grade: "SEVERE AP", color: C.red, bgColor: "2D0A0A",
      points: ["Persistent organ failure (> 48 h)", "Single or multi-organ failure", "Mortality: 30–50% (higher if infected necrosis)", "Requires ICU admission", "Multi-disciplinary team management"] },
  ];
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    const x = 0.5 + i * 4.15;
    s.addShape(pres.ShapeType.roundRect, { x, y: 1.35, w: 3.95, h: 5.55, rectRadius: 0.12, fill: { color: g.bgColor }, line: { color: g.color, pt: 2.5 } });
    s.addText(g.grade, { x, y: 1.42, w: 3.95, h: 0.6, fontSize: 13, bold: true, color: g.color, fontFace: "Calibri", align: "center" });
    g.points.forEach((p, j) => {
      s.addText("• " + p, { x: x + 0.15, y: 2.15 + j * 0.82, w: 3.65, h: 0.75, fontSize: 13, color: C.white, fontFace: "Calibri", valign: "top" });
    });
  });
  s.addText("Organ failure defined by modified Marshall scoring: PaO₂/FiO₂ < 300 | Creatinine > 1.9 mg/dL | SBP < 90 mmHg despite fluids", { x: 0.5, y: 7.0, w: 12.3, h: 0.4, fontSize: 11, color: C.gray, fontFace: "Calibri", italic: true });
}

// Ranson's Criteria
{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Ranson's Criteria & Other Scoring Systems");

  // Ranson table
  s.addText("RANSON'S CRITERIA", { x: 0.5, y: 1.35, w: 5.9, h: 0.4, fontSize: 14, bold: true, color: C.navy, fontFace: "Calibri" });
  const ransonData = [
    [{ text: "On Admission", options: { bold: true, color: C.white, fill: { color: C.slate } } },
     { text: "At 48 Hours", options: { bold: true, color: C.white, fill: { color: C.slate } } }],
    [{ text: "Age > 55 years", options: { color: C.navy } }, { text: "Hematocrit drop > 10%", options: { color: C.navy } }],
    [{ text: "WBC > 16,000/mm³", options: { color: C.navy } }, { text: "BUN rise > 5 mg/dL", options: { color: C.navy } }],
    [{ text: "Blood glucose > 200 mg/dL", options: { color: C.navy } }, { text: "Serum Ca²⁺ < 8 mg/dL", options: { color: C.navy } }],
    [{ text: "Serum LDH > 350 IU/L", options: { color: C.navy } }, { text: "PaO₂ < 60 mmHg", options: { color: C.navy } }],
    [{ text: "AST > 250 IU/L", options: { color: C.navy } }, { text: "Base deficit > 4 mEq/L", options: { color: C.navy } }],
    [{ text: "", options: { color: C.navy } }, { text: "Fluid sequestration > 6L", options: { color: C.navy } }],
  ];
  s.addTable(ransonData, { x: 0.5, y: 1.78, w: 6.1, colW: [3.05, 3.05], border: { type: "solid", pt: 0.5, color: C.grayLight }, fontFace: "Calibri", fontSize: 12.5, rowH: 0.36 });
  s.addText("Score ≥ 3 = Severe  |  Score ≥ 5 = High mortality (>40%)", { x: 0.5, y: 4.5, w: 6.1, h: 0.35, fontSize: 12, color: C.red, fontFace: "Calibri", bold: true });

  // Other scores
  s.addText("OTHER SCORING SYSTEMS", { x: 7.0, y: 1.35, w: 5.9, h: 0.4, fontSize: 14, bold: true, color: C.navy, fontFace: "Calibri" });
  const others = [
    { name: "APACHE II", detail: "12 physiology variables + age + chronic health. Score ≥ 8 = severe. Applicable on admission and repeated daily." },
    { name: "BISAP Score", detail: "5 variables (BUN > 25, Impaired mental status, SIRS, Age > 60, Pleural effusion). Score ≥ 3 = severe." },
    { name: "CT Severity Index (CTSI)", detail: "Balthazar grade (A–E) + % necrosis. Score 7–10 = severe. Correlates with morbidity and mortality." },
    { name: "CRP at 48 h", detail: "CRP > 150 mg/L at 48 h is a reliable predictor of severe AP. Simple, widely available." },
  ];
  others.forEach((o, i) => {
    const y = 1.8 + i * 1.28;
    s.addShape(pres.ShapeType.roundRect, { x: 7.0, y, w: 6.0, h: 1.15, rectRadius: 0.1, fill: { color: C.navy }, line: { color: C.teal, pt: 1.2 } });
    s.addText(o.name, { x: 7.1, y: y + 0.06, w: 5.8, h: 0.38, fontSize: 13.5, bold: true, color: C.teal, fontFace: "Calibri" });
    s.addText(o.detail, { x: 7.1, y: y + 0.48, w: 5.8, h: 0.62, fontSize: 12.5, color: C.white, fontFace: "Calibri", valign: "top" });
  });
  s.addText("Glasgow/Imrie criteria: identical concept to Ranson, validated in UK. Score ≥ 3 = severe.", { x: 0.5, y: 7.05, w: 12.3, h: 0.32, fontSize: 11, color: C.gray, fontFace: "Calibri", italic: true });
}

// ═══════════════════════════════════════════════════════════════
// SECTION 6 — IMAGING
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 6", "Imaging in Acute Pancreatitis");

{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Imaging Modalities", "Complementary roles — choose based on clinical context");

  const modalities = [
    { title: "Abdominal Ultrasound", color: "2ECC71",
      items: ["First-line imaging in all patients", "Detects gallstones, biliary sludge, CBD dilation", "Limited by bowel gas and obesity", "Cannot reliably assess pancreatic necrosis", "Sensitive for detecting gallstone etiology"] },
    { title: "CECT Abdomen", color: C.teal,
      items: ["Gold standard for severity and complications", "Identifies pancreatic/peripancreatic necrosis", "Non-enhancing pancreas = necrotic parenchyma", "Best performed at 48–72 h (necrosis not visible earlier)", "CT Severity Index (CTSI) calculated from CECT"] },
    { title: "MRI / MRCP", color: C.amber,
      items: ["Equivalent to CT for necrosis detection", "Superior for duct anatomy and gallstones", "MRCP: non-invasive ductal imaging", "Preferred if CT contraindicated (pregnancy, allergy)", "Better for solid vs. liquid component differentiation"] },
    { title: "EUS & ERCP", color: C.red,
      items: ["EUS: detects microlithiasis, ampullary adenoma, malignancy", "EUS preferred over ERCP for diagnosis", "ERCP: therapeutic only — not for diagnosis", "ERCP within 24 h: if cholangitis or persistent biliary obstruction", "Sphincterotomy + stone extraction in gallstone AP with cholangitis"] },
  ];
  modalities.forEach((m, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.5 + col * 6.55;
    const y = 1.35 + row * 2.95;
    s.addShape(pres.ShapeType.roundRect, { x, y, w: 6.2, h: 2.75, rectRadius: 0.12, fill: { color: C.navy }, line: { color: m.color, pt: 2 } });
    s.addText(m.title, { x: x + 0.15, y: y + 0.1, w: 5.9, h: 0.4, fontSize: 14, bold: true, color: m.color, fontFace: "Calibri" });
    m.items.forEach((item, j) => {
      s.addText("• " + item, { x: x + 0.15, y: y + 0.58 + j * 0.42, w: 5.9, h: 0.4, fontSize: 12.5, color: C.white, fontFace: "Calibri", valign: "top" });
    });
  });
}

// CT Severity Index
{
  const s = lightSlide(pres);
  slideTitle(s, pres, "CT Severity Index (Balthazar / CTSI)", "Combines CT grade + % necrosis");

  // Balthazar
  s.addText("BALTHAZAR GRADE (CT Inflammation)", { x: 0.5, y: 1.35, w: 5.9, h: 0.4, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  const bData = [
    [{ text: "Grade", options: { bold: true, fill: { color: C.slate }, color: C.white } },
     { text: "CT Findings", options: { bold: true, fill: { color: C.slate }, color: C.white } },
     { text: "Points", options: { bold: true, fill: { color: C.slate }, color: C.white } }],
    [{ text: "A", options: {} }, { text: "Normal pancreas", options: {} }, { text: "0", options: {} }],
    [{ text: "B", options: {} }, { text: "Focal/diffuse enlargement", options: {} }, { text: "1", options: {} }],
    [{ text: "C", options: {} }, { text: "Pancreatic + peripancreatic inflammation", options: {} }, { text: "2", options: {} }],
    [{ text: "D", options: {} }, { text: "Single peripancreatic fluid collection", options: {} }, { text: "3", options: {} }],
    [{ text: "E", options: {} }, { text: "≥2 fluid collections / retroperitoneal gas", options: {} }, { text: "4", options: {} }],
  ];
  s.addTable(bData, { x: 0.5, y: 1.8, w: 6.1, colW: [0.8, 4.2, 1.1], border: { type: "solid", pt: 0.5, color: C.grayLight }, fontFace: "Calibri", fontSize: 12.5, rowH: 0.36 });

  // Necrosis
  s.addText("NECROSIS SCORE", { x: 7.0, y: 1.35, w: 5.9, h: 0.4, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  const nData = [
    [{ text: "Necrosis (%)", options: { bold: true, fill: { color: C.slate }, color: C.white } },
     { text: "Points", options: { bold: true, fill: { color: C.slate }, color: C.white } }],
    [{ text: "None", options: {} }, { text: "0", options: {} }],
    [{ text: "< 30%", options: {} }, { text: "2", options: {} }],
    [{ text: "30–50%", options: {} }, { text: "4", options: {} }],
    [{ text: "> 50%", options: {} }, { text: "6", options: {} }],
  ];
  s.addTable(nData, { x: 7.0, y: 1.8, w: 3.5, colW: [2.2, 1.3], border: { type: "solid", pt: 0.5, color: C.grayLight }, fontFace: "Calibri", fontSize: 12.5, rowH: 0.36 });

  // Interpretation
  s.addText("CTSI = Balthazar + Necrosis Points (Max = 10)", { x: 7.0, y: 3.65, w: 5.9, h: 0.45, fontSize: 13, bold: true, color: C.teal, fontFace: "Calibri" });
  const interpData = [
    [{ text: "CTSI Score", options: { bold: true, fill: { color: C.slate }, color: C.white } },
     { text: "Severity", options: { bold: true, fill: { color: C.slate }, color: C.white } },
     { text: "Morbidity", options: { bold: true, fill: { color: C.slate }, color: C.white } }],
    [{ text: "0–3", options: {} }, { text: "Mild", options: { color: "2ECC71" } }, { text: "Low", options: {} }],
    [{ text: "4–6", options: {} }, { text: "Moderate", options: { color: C.amber } }, { text: "35%", options: {} }],
    [{ text: "7–10", options: {} }, { text: "Severe", options: { color: C.red } }, { text: "92%", options: {} }],
  ];
  s.addTable(interpData, { x: 7.0, y: 4.15, w: 5.9, colW: [1.8, 2.4, 1.7], border: { type: "solid", pt: 0.5, color: C.grayLight }, fontFace: "Calibri", fontSize: 13, rowH: 0.42 });

  // Local complications
  s.addText("LOCAL COMPLICATIONS (Revised Atlanta 2012)", { x: 0.5, y: 4.65, w: 5.9, h: 0.4, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  const lc = [
    ["Acute Peripancreatic Fluid Collection (APFC)", "< 4 weeks, interstitial AP, no wall, no necrosis"],
    ["Acute Necrotic Collection (ANC)", "< 4 weeks, necrotizing AP, no wall, contains necrosis"],
    ["Pseudocyst", "> 4 weeks, wall-encapsulated, no solid necrotic material"],
    ["Walled-Off Necrosis (WON)", "> 4 weeks, wall-encapsulated, contains necrosis"],
  ];
  lc.forEach(([name, detail], i) => {
    s.addShape(pres.ShapeType.roundRect, { x: 0.5, y: 5.12 + i * 0.52, w: 12.3, h: 0.48, rectRadius: 0.08, fill: { color: i % 2 === 0 ? C.navy : C.slateLight }, line: { type: "none" } });
    s.addText(name, { x: 0.65, y: 5.14 + i * 0.52, w: 4.5, h: 0.4, fontSize: 12, bold: true, color: C.teal, fontFace: "Calibri" });
    s.addText(detail, { x: 5.2, y: 5.14 + i * 0.52, w: 7.5, h: 0.4, fontSize: 12, color: C.white, fontFace: "Calibri" });
  });
}

// ═══════════════════════════════════════════════════════════════
// SECTION 7 — MANAGEMENT: INITIAL RESUSCITATION
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 7", "Management — Initial Resuscitation");

{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Initial Management: First 24–48 Hours", "Aggressive resuscitation is the cornerstone of treatment");

  const cols = [
    { title: "FLUID RESUSCITATION", color: C.teal, x: 0.5, items: [
      "Goal-directed IV fluid therapy — most important intervention",
      "Lactated Ringer's preferred over Normal Saline",
      "  LR reduces SIRS and inflammatory markers",
      "Rate: 250–500 mL/h in first 12–24 h (guided by response)",
      "Monitor: Urine output > 0.5 mL/kg/h, HR < 100, MAP > 65",
      "BUN and hematocrit — bedside surrogates of resuscitation",
      "Avoid over-hydration: worsens abdominal compartment syndrome",
    ]},
    { title: "ANALGESIA", color: C.amber, x: 4.65, items: [
      "Adequate pain control is mandatory",
      "IV opioids (morphine, hydromorphone) — first line",
      "  No evidence that morphine worsens pancreatitis (historical myth)",
      "NSAIDs / ketorolac as adjuncts",
      "Epidural analgesia — consider in refractory severe pain",
      "Reassess frequently — pain correlates with inflammation",
    ]},
    { title: "MONITORING", color: C.red, x: 8.8, items: [
      "ICU admission if: persistent organ failure, APACHE ≥ 8",
      "Vital signs q1h in severe AP",
      "Foley catheter for urine output monitoring",
      "Serial abdominal exams for peritoneal signs",
      "Repeat labs at 24 h (WBC, BUN, Hct, CRP, LFTs)",
      "CECT if no improvement at 48–72 h",
    ]},
  ];
  cols.forEach(col => {
    s.addShape(pres.ShapeType.roundRect, { x: col.x, y: 1.35, w: 3.95, h: 5.55, rectRadius: 0.12, fill: { color: C.navy }, line: { color: col.color, pt: 2 } });
    s.addText(col.title, { x: col.x + 0.1, y: 1.42, w: 3.75, h: 0.45, fontSize: 12.5, bold: true, color: col.color, fontFace: "Calibri", align: "center" });
    col.items.forEach((item, i) => {
      const isSub = item.startsWith("  ");
      const text = item.replace(/^\s+/, "");
      s.addText((isSub ? "  ↳ " : "• ") + text, { x: col.x + 0.12, y: 1.95 + i * 0.72, w: 3.7, h: 0.68, fontSize: isSub ? 12 : 13, color: isSub ? C.grayLight : C.white, fontFace: "Calibri", valign: "top" });
    });
  });
  s.addText("Discontinue oral intake initially — reassess at 24 h. Most mild AP patients can resume oral feeding within 24–48 h if pain and nausea allow.", { x: 0.5, y: 7.0, w: 12.3, h: 0.38, fontSize: 11.5, color: C.slateLight, fontFace: "Calibri", italic: true });
}

// ═══════════════════════════════════════════════════════════════
// SECTION 8 — NUTRITION & PHARMACOTHERAPY
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 8", "Nutrition & Pharmacotherapy");

{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Nutritional Management", "Enteral nutrition is superior to parenteral nutrition");

  // Left: mild AP
  s.addShape(pres.ShapeType.roundRect, { x: 0.5, y: 1.35, w: 5.9, h: 4.35, rectRadius: 0.12, fill: { color: C.navy }, line: { color: "2ECC71", pt: 2 } });
  s.addText("MILD AP", { x: 0.6, y: 1.42, w: 5.7, h: 0.45, fontSize: 15, bold: true, color: "2ECC71", fontFace: "Calibri" });
  bulletBox(s, pres, [
    "Resume oral diet as soon as pain and nausea allow",
    "  Typically within 24–48 hours",
    "Start with soft/low-fat diet (not necessarily clear liquids)",
    "Early oral feeding reduces hospital stay",
    "Nasogastric tube only if persistent vomiting",
    "IV fluids can be de-escalated once oral intake established",
  ], { x: 0.6, y: 1.92, w: 5.7, h: 3.6, fontSize: 13.5 });

  // Right: severe AP
  s.addShape(pres.ShapeType.roundRect, { x: 6.9, y: 1.35, w: 5.9, h: 4.35, rectRadius: 0.12, fill: { color: C.navy }, line: { color: C.red, pt: 2 } });
  s.addText("SEVERE AP", { x: 7.0, y: 1.42, w: 5.7, h: 0.45, fontSize: 15, bold: true, color: C.red, fontFace: "Calibri" });
  bulletBox(s, pres, [
    "Enteral nutrition (EN) is PREFERRED over TPN",
    "  EN maintains gut barrier, reduces bacterial translocation",
    "  EN reduces infection risk, organ failure, and mortality",
    "Nasojejunal (post-ligament of Treitz) feeding preferred",
    "  Nasogastric route acceptable if NJ not feasible",
    "Start EN within 24–48 h in severe AP",
    "TPN: reserved for EN intolerance or inaccessible GI tract",
  ], { x: 7.0, y: 1.92, w: 5.7, h: 3.6, fontSize: 13.5 });

  // Bottom summary
  s.addShape(pres.ShapeType.roundRect, { x: 0.5, y: 5.85, w: 12.3, h: 1.0, rectRadius: 0.1, fill: { color: C.teal, transparency: 10 }, line: { type: "none" } });
  s.addText([
    { text: "KEY PRINCIPLE: ", options: { bold: true, fontSize: 14, color: C.navy } },
    { text: "\"Resting the pancreas\" by NPO is outdated. Early enteral feeding is now standard of care for severe AP. The gut is not a bystander — it is an active source of infection when starved.", options: { fontSize: 13.5, color: C.navy } },
  ], { x: 0.65, y: 5.9, w: 12.0, h: 0.9, fontFace: "Calibri", valign: "middle" });
}

// Pharmacotherapy
{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Pharmacotherapy & What NOT to Use");

  const meds = [
    { title: "ANTIBIOTICS", color: C.amber,
      items: ["NOT routinely indicated in AP — no benefit for sterile disease",
              "Prophylactic antibiotics in necrotizing AP: NOT recommended (multiple RCTs negative)",
              "INDICATIONS: Infected pancreatic necrosis (fever + elevated WBC persisting > 7–10 d)",
              "Choice: Carbapenems (imipenem) or fluoroquinolones — good pancreatic penetration",
              "FNA-guided culture before starting antibiotics if possible"] },
    { title: "PROTON PUMP INHIBITORS", color: C.teal,
      items: ["Routine use NOT evidence-based for pancreatitis per se",
              "Use if co-existing peptic ulcer disease or stress ulcer prophylaxis in ICU patients",
              "Stress ulcer prophylaxis: IV PPI in ventilated ICU patients"] },
    { title: "OCTREOTIDE / PROTEASE INHIBITORS", color: C.red,
      items: ["Octreotide, gabexate, aprotinin: NOT recommended — no mortality benefit",
              "Multiple randomized trials negative",
              "No role for routine somatostatin analog therapy in AP"] },
    { title: "OTHER ADJUNCTS", color: C.gray,
      items: ["Antispasmodics (hyoscine): mild symptom relief only",
              "Insulin: required if glucose > 180–200 mg/dL (hypertriglyceridemic AP)",
              "Plasmapheresis: for extreme hypertriglyceridemia (>1000 mg/dL) refractory to insulin",
              "Anticoagulation: for splenic/portal vein thrombosis complicating AP"] },
  ];
  meds.forEach((m, i) => {
    const col = i % 2;
    const row = Math.floor(i / 2);
    const x = 0.5 + col * 6.55;
    const y = 1.35 + row * 2.95;
    s.addShape(pres.ShapeType.roundRect, { x, y, w: 6.2, h: 2.75, rectRadius: 0.12, fill: { color: C.navy }, line: { color: m.color, pt: 1.8 } });
    s.addText(m.title, { x: x + 0.12, y: y + 0.1, w: 5.9, h: 0.4, fontSize: 13.5, bold: true, color: m.color, fontFace: "Calibri" });
    m.items.forEach((item, j) => {
      s.addText("• " + item, { x: x + 0.12, y: y + 0.58 + j * 0.44, w: 5.9, h: 0.42, fontSize: 12, color: C.white, fontFace: "Calibri", valign: "top" });
    });
  });
}

// ═══════════════════════════════════════════════════════════════
// SECTION 9 — COMPLICATIONS & INTERVENTIONS
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 9", "Complications & Interventional Management");

{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Systemic Complications & Organ Failure", "Multiorgan failure drives mortality in severe AP");

  const comps = [
    { title: "RESPIRATORY", color: C.teal,
      items: ["ARDS — most feared; PaO₂/FiO₂ < 200", "Pleural effusions (left > right)", "Atelectasis, pneumonia", "Manage: lung-protective ventilation, diuresis"] },
    { title: "RENAL", color: C.amber,
      items: ["Acute kidney injury — 2nd to hypovolemia", "Hemoconcentration (Hct > 44%) = risk factor", "Goal: urine output > 0.5 mL/kg/h", "Dialysis if refractory oliguria"] },
    { title: "CARDIOVASCULAR", color: C.red,
      items: ["Hypovolemic shock — aggressive IVF", "Myocardial depression (cytokine-mediated)", "Splenic/portal vein thrombosis", "Monitor: MAP > 65, avoid vasopressors when possible"] },
    { title: "METABOLIC", color: "9B59B6",
      items: ["Hypocalcemia — saponification of fat", "  Ca²⁺ < 8 mg/dL = Ranson criterion", "Hyperglycemia — stress response", "Hypomagnesemia, hypophosphatemia"] },
    { title: "HEMATOLOGIC", color: "E74C3C",
      items: ["DIC — rare, fulminant course", "Anemia from retroperitoneal hemorrhage", "Thrombocytopenia in septic complications"] },
    { title: "INFECTIOUS", color: C.amber,
      items: ["Infected pancreatic necrosis — most feared complication", "Bacteremia, sepsis, multi-organ failure", "Mortality rises to 30–50% with infection", "Abscesses in peripancreatic collections"] },
  ];
  comps.forEach((c, i) => {
    const col = i % 3;
    const row = Math.floor(i / 3);
    const x = 0.4 + col * 4.3;
    const y = 1.35 + row * 2.85;
    s.addShape(pres.ShapeType.roundRect, { x, y, w: 4.0, h: 2.65, rectRadius: 0.1, fill: { color: C.navy }, line: { color: c.color, pt: 1.8 } });
    s.addText(c.title, { x: x + 0.1, y: y + 0.1, w: 3.8, h: 0.38, fontSize: 13, bold: true, color: c.color, fontFace: "Calibri" });
    c.items.forEach((item, j) => {
      const isSub = item.startsWith("  ");
      s.addText((isSub ? "  ↳ " : "• ") + item.trim(), { x: x + 0.1, y: y + 0.55 + j * 0.52, w: 3.8, h: 0.5, fontSize: isSub ? 11.5 : 12.5, color: isSub ? C.grayLight : C.white, fontFace: "Calibri", valign: "top" });
    });
  });
}

// Interventional Management
{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Interventional & Surgical Management", "Step-up approach — minimally invasive first");

  // Step-up approach
  s.addText("STEP-UP APPROACH FOR INFECTED NECROSIS", { x: 0.5, y: 1.35, w: 12.3, h: 0.45, fontSize: 15, bold: true, color: C.navy, fontFace: "Calibri" });
  const steps = [
    { n: "STEP 1", title: "Conservative Management", detail: "Antibiotics (IV carbapenem). Continue enteral nutrition. Monitor for clinical deterioration. Allow 2–4 weeks for demarcation of necrosis.", color: "2ECC71" },
    { n: "STEP 2", title: "Percutaneous / Endoscopic Drainage", detail: "CT-guided percutaneous catheter drainage (PCD). Endoscopic transmural drainage (ETD) for WON adjacent to gut wall. Preferred if well-demarcated WON > 4 weeks.", color: C.amber },
    { n: "STEP 3", title: "Video-Assisted Retroperitoneal Debridement (VARD)", detail: "Minimally invasive necrosectomy via retroperitoneal route. Performed via sinus tract of PCD catheter. Lower morbidity than open surgery.", color: C.red },
    { n: "STEP 4", title: "Open Surgical Necrosectomy", detail: "Reserved for failed endoscopic/percutaneous approaches. Last resort — highest morbidity and mortality. Laparostomy or open packing techniques.", color: "8E44AD" },
  ];
  steps.forEach((step, i) => {
    const y = 1.92 + i * 1.3;
    s.addShape(pres.ShapeType.roundRect, { x: 0.5, y, w: 1.5, h: 1.1, rectRadius: 0.1, fill: { color: step.color }, line: { type: "none" } });
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    s.addText(step.title, { x: 2.5, y: y + 0.1, w: 10.0, h: 0.38, fontSize: 13, bold: true, color: step.color, fontFace: "Calibri" });
    s.addText(step.detail, { x: 2.5, y: y + 0.5, w: 10.0, h: 0.52, fontSize: 12, color: C.white, fontFace: "Calibri", valign: "top" });
  });
  s.addText("ERCP with sphincterotomy: within 24 h for gallstone AP with concurrent cholangitis or persisting biliary obstruction.", { x: 0.5, y: 7.1, w: 12.3, h: 0.32, fontSize: 11, color: C.gray, fontFace: "Calibri", italic: true });
}

// Gallstone AP management
{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Gallstone Pancreatitis — Specific Management");

  bulletBox(s, pres, [
    "## ERCP INDICATIONS",
    "Acute cholangitis complicating gallstone AP → ERCP within 24 hours",
    "Persistent biliary obstruction (rising bilirubin, dilated CBD) → ERCP within 48–72 h",
    "ERCP NOT indicated: mild gallstone AP without cholangitis or obstruction",
    "## CHOLECYSTECTOMY TIMING",
    "Mild AP: Cholecystectomy during SAME ADMISSION (within 7 days) → prevents recurrence (30–50% risk within 30 days without surgery)",
    "Moderate-Severe AP: Delay cholecystectomy until inflammation resolves (≥ 4–6 weeks)",
    "If ERCP sphincterotomy performed: still requires cholecystectomy (sphincterotomy alone insufficient)",
    "## HYPERTRIGLYCERIDEMIA-INDUCED AP",
    "Insulin infusion (even without diabetes) — lowers triglycerides rapidly",
    "Plasmapheresis if TG > 1000 mg/dL unresponsive to insulin",
    "Long-term: fibrates, omega-3 fatty acids, low-fat diet",
    "## ALCOHOL-INDUCED AP",
    "Abstinence counseling — reduces recurrence and progression to chronic pancreatitis",
    "Brief intervention during hospitalization shown to reduce recurrence",
  ], { fontSize: 14 });
}

// ═══════════════════════════════════════════════════════════════
// SECTION 10 — SPECIAL SCENARIOS & FOLLOW-UP
// ═══════════════════════════════════════════════════════════════
sectionHeader(pres, "Section 10", "Special Scenarios & Follow-Up");

{
  const s = lightSlide(pres);
  slideTitle(s, pres, "Post-Discharge Management & Prevention of Recurrence");

  bulletBox(s, pres, [
    "## POST-DISCHARGE FOLLOW-UP",
    "All patients: follow-up at 2–4 weeks; review imaging findings and labs",
    "Pseudocyst / WON: repeat CT at 6–8 weeks if not drained",
    "Assess for exocrine insufficiency (steatorrhea) and endocrine insufficiency (new-onset diabetes)",
    "## PREVENTION OF RECURRENCE",
    "Gallstone AP: SAME-ADMISSION cholecystectomy (see slide 15)",
    "Alcohol AP: abstinence support, addiction referral",
    "Hypertriglyceridemia: fibrates, dietary fat restriction, omega-3 fatty acids",
    "Medication-induced AP: permanent discontinuation of offending agent",
    "## RISK OF CHRONIC PANCREATITIS",
    "Each episode of AP causes progressive fibrosis",
    "Recurrent AP → Chronic pancreatitis continuum",
    "Smoking: strongest modifiable risk factor for progression",
    "Genetic AP (PRSS1 mutations): very high risk → monitoring for exocrine and endocrine insufficiency",
    "## LONG-TERM COMPLICATIONS TO MONITOR",
    "Pancreatic exocrine insufficiency: enzyme replacement therapy (PERT)",
    "Post-AP diabetes mellitus (type 3c): insulin therapy, monitoring HbA1c",
    "Splenic and portal vein thrombosis: anticoagulation 3–6 months",
    "Pancreatic ductal strictures: ERCP / surgery if symptomatic",
  ], { fontSize: 13.5 });
}

// ═══════════════════════════════════════════════════════════════
// SUMMARY SLIDE
// ═══════════════════════════════════════════════════════════════
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  s.addText("CLINICAL PEARLS & TAKE-HOME MESSAGES", { x: 0.5, y: 0.15, w: 12.3, h: 0.7, fontSize: 26, bold: true, color: C.white, fontFace: "Calibri" });

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    { n: "1", text: "Diagnosis: 2 of 3 — characteristic pain + lipase ≥3× ULN + imaging. Lipase > amylase in sensitivity and duration.", color: "2ECC71" },
    { n: "2", text: "Severity: Revised Atlanta 2012 (mild / moderately severe / severe). Persistent organ failure > 48 h = severe. CTSI, APACHE II, BISAP — use multiple tools.", color: C.teal },
    { n: "3", text: "Fluid resuscitation: Lactated Ringer's preferred. 250–500 mL/h goal-directed. Most important initial intervention.", color: C.amber },
    { n: "4", text: "Nutrition: Early enteral feeding (24–48 h). Enteral > parenteral. Nasojejunal preferred. NPO is outdated for severe AP.", color: "9B59B6" },
    { n: "5", text: "Antibiotics: NOT prophylactic. Reserve for CONFIRMED infected necrosis. Carbapenems / quinolones for good pancreatic penetration.", color: C.red },
    { n: "6", text: "Interventions: Step-up approach — conservative → endoscopic/percutaneous drainage → VARD → open necrosectomy.", color: "E67E22" },
    { n: "7", text: "Gallstone AP: ERCP if cholangitis. Same-admission cholecystectomy for mild AP. Delay 4–6 weeks for severe AP.", color: "1ABC9C" },
    { n: "8", text: "Follow-up: Monitor for exocrine insufficiency, new-onset diabetes (type 3c), and strictures. Address modifiable causes.", color: C.gray },
  ];
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// FINAL SLIDE
{
  const s = darkSlide(pres);
  s.addShape(pres.ShapeType.ellipse, { x: 3.5, y: 1.2, w: 6.3, h: 6.3, fill: { color: C.teal, transparency: 90 }, line: { type: "none" } });
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 7.42, w: "100%", h: 0.08, fill: { color: C.teal }, line: { type: "none" } });
  s.addText("THANK YOU", { x: 1.5, y: 2.2, w: 10.3, h: 1.1, fontSize: 52, bold: true, color: C.white, fontFace: "Calibri", align: "center", charSpacing: 8 });
  s.addText("Questions & Discussion", { x: 1.5, y: 3.4, w: 10.3, h: 0.65, fontSize: 24, color: C.teal, fontFace: "Calibri", align: "center" });
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  s.addText("Goldman-Cecil Medicine (26e)  •  Sleisenger & Fordtran's GI and Liver Disease  •  Robbins & Kumar Basic Pathology  •  Rosen's Emergency Medicine", { x: 0.5, y: 4.4, w: 12.3, h: 0.5, fontSize: 11.5, color: C.gray, fontFace: "Calibri", align: "center" });
}

// ─── WRITE FILE ──────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/acute-pancreatitis-pptx/Acute_Pancreatitis_PG.pptx" })
  .then(() => console.log("DONE: Acute_Pancreatitis_PG.pptx written"))
  .catch(err => console.error("ERROR:", err));

cd /home/daytona/workspace/acute-pancreatitis-pptx && node build.js 2>&1

ls -lh /home/daytona/workspace/acute-pancreatitis-pptx/Acute_Pancreatitis_PG.ppt…