multiple sclerosis MRI brain lesions demyelination

multiple sclerosis rehabilitation physiotherapy exercise spasticity

ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not foun…

mkdir -p /home/daytona/workspace/ms-presentation && echo "done"

~/ms-presentation/create_ms_pptx.js

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─── Fetch images ────────────────────────────────────────────────────────────
const imageUrls = [
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_9c900f79f0a744bb3622285f17238eec399a8d2365df206c4e771463f5973166.jpg", // MRI Dawson's fingers + spinal cord
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_672f78c9ca25dd77dce2d71f20dc6b259bef9c1492e3f61a10e034d82f06631a.jpg", // MRI T2 + Gd enhancing
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_37046fdcb0f81e355af3478e1960f9fc301bd618bf757a8832c71d0f50badcbf.jpg", // Bobath rehab
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_49416c83da33751f3c311cbc419fb9f48c4ad47bb75f09e2d8fa748414e13480.jpg", // spasticity management
];

let imgs = [];
try {
  const result = execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  ).toString();
  imgs = JSON.parse(result);
} catch (e) {
  console.error("Image fetch failed:", e.message);
  imgs = imageUrls.map(() => ({ base64: null, error: e.message }));
}

// ─── Color palette ───────────────────────────────────────────────────────────
const C = {
  navy:    "0D2B55",   // dominant dark
  teal:    "1B6CA8",   // secondary blue
  accent:  "E8F4FD",   // light blue fill
  white:   "FFFFFF",
  gold:    "E9A21B",   // highlight accent
  dark:    "1A1A2E",
  text:    "1C2B3A",
  muted:   "6B7C8D",
  red:     "C0392B",
  green:   "1E8449",
  lightbg: "F0F7FF",
};

// ─── Presentation ────────────────────────────────────────────────────────────
let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Multiple Sclerosis – Case Presentation";
pres.author = "Department of Physical Medicine & Rehabilitation";

// ═══════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════
{
  let s = pres.addSlide();
  // Full background gradient via rectangle
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navy } });
  // decorative side bar
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });
  // big title
  s.addText("MULTIPLE SCLEROSIS", {
    x: 0.4, y: 0.8, w: 9.2, h: 1.1,
    fontSize: 40, bold: true, color: C.white,
    fontFace: "Calibri", align: "center", charSpacing: 3,
  });
  s.addText("A Case-Based Presentation", {
    x: 0.4, y: 1.95, w: 9.2, h: 0.55,
    fontSize: 22, color: C.gold, fontFace: "Calibri", align: "center", italic: true,
  });
  // divider line
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  s.addText("Department of Physical Medicine & Rehabilitation", {
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    fontSize: 16, color: C.accent, fontFace: "Calibri", align: "center",
  });
  s.addText("Relapsing-Remitting MS  |  Diagnosis  |  Rehabilitation Management", {
    x: 0.4, y: 3.3, w: 9.2, h: 0.4,
    fontSize: 13, color: C.muted, fontFace: "Calibri", align: "center",
  });
  // footer
  s.addText("May 2026", {
    x: 0.4, y: 5.1, w: 9.2, h: 0.35,
    fontSize: 11, color: C.muted, align: "center", fontFace: "Calibri",
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 2 — CASE PRESENTATION
// ═══════════════════════════════════════════════════════
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  s.addText("CASE PRESENTATION", {
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    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
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  // Patient card
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    fontSize: 13, bold: true, color: C.teal, fontFace: "Calibri",
  });
  const patientInfo = [
    { label: "Name:", value: "Ms. S.R." },
    { label: "Age:", value: "28 years" },
    { label: "Sex:", value: "Female" },
    { label: "Occupation:", value: "Software Engineer" },
    { label: "Referred by:", value: "Neurology Dept." },
  ];
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    s.addText([
      { text: item.label + " ", options: { bold: true, color: C.navy } },
      { text: item.value, options: { color: C.text } },
    ], { x: 0.5, y: 1.35 + i * 0.55, w: 3.8, h: 0.44, fontSize: 13, fontFace: "Calibri" });
  });

  // Chief complaints card
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    x: 4.8, y: 0.9, w: 4.8, h: 0.38,
    fontSize: 13, bold: true, color: C.gold, fontFace: "Calibri",
  });
  const complaints = [
    "Sudden loss of vision in right eye → 3 weeks ago",
    "Painful eye movements (retro-orbital pain)",
    "Progressive weakness in both lower limbs → 2 months",
    "Tingling & numbness below waist level",
    "Urgency & hesitancy of micturition",
    "Fatigue limiting daily activities",
  ];
  complaints.forEach((item, i) => {
    s.addText([
      { text: "▸  ", options: { color: C.gold, bold: true } },
      { text: item, options: { color: C.text } },
    ], { x: 4.85, y: 1.35 + i * 0.52, w: 4.7, h: 0.44, fontSize: 12, fontFace: "Calibri" });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 3 — HISTORY OF PRESENT ILLNESS
// ═══════════════════════════════════════════════════════
{
  let s = pres.addSlide();
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.teal } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });

  s.addText("HISTORY OF PRESENT ILLNESS", {
    x: 0.35, y: 0.1, w: 9.4, h: 0.52,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
  });

  const timeline = [
    { time: "2 Years Ago", color: C.navy, detail: "Episode of diplopia lasting 4 weeks → resolved spontaneously. No workup done." },
    { time: "6 Months Ago", color: C.teal, detail: "Unsteady gait, ataxia for 3 weeks → partially resolved. Dismissed as 'stress-related'." },
    { time: "2 Months Ago", color: C.gold, detail: "Progressive bilateral lower limb weakness and sensory disturbance below T10 level." },
    { time: "3 Weeks Ago", color: C.red, detail: "Sudden painful vision loss OD (right eye) — diagnosed as optic neuritis at ER." },
    { time: "Present", color: C.green, detail: "Referred to PM&R for comprehensive rehabilitation assessment and management planning." },
  ];

  timeline.forEach((item, i) => {
    const y = 0.88 + i * 0.89;
    s.addShape(pres.ShapeType.rect, { x: 0.35, y, w: 1.5, h: 0.65, fill: { color: item.color } });
    s.addText(item.time, { x: 0.35, y, w: 1.5, h: 0.65, fontSize: 11, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addShape(pres.ShapeType.rect, { x: 1.85, y: y + 0.08, w: 7.9, h: 0.55, fill: { color: C.white }, line: { color: item.color, width: 1 } });
    s.addText(item.detail, { x: 2.0, y: y + 0.07, w: 7.6, h: 0.58, fontSize: 12, color: C.text, fontFace: "Calibri", valign: "middle" });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 4 — PAST HISTORY & EXAMINATION
// ═══════════════════════════════════════════════════════
{
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });

  s.addText("PAST HISTORY & PHYSICAL EXAMINATION", {
    x: 0.35, y: 0.1, w: 9.4, h: 0.52,
    fontSize: 20, bold: true, color: C.white, fontFace: "Calibri",
  });

  // Left column
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0.85, w: 4.35, h: 4.55, fill: { color: C.white }, line: { color: C.navy, width: 1 } });
  s.addText("PAST MEDICAL HISTORY", { x: 0.45, y: 0.9, w: 4.1, h: 0.38, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  const past = [
    "No known chronic illnesses",
    "No prior neurological diagnosis",
    "No recent infections or vaccinations",
    "Family history: maternal aunt with MS",
    "Non-smoker, no alcohol/drug use",
    "No relevant drug history",
  ];
  past.forEach((item, i) => {
    s.addText([{ text: "• ", options: { color: C.teal, bold: true } }, { text: item, options: { color: C.text } }],
      { x: 0.5, y: 1.38 + i * 0.49, w: 4.0, h: 0.42, fontSize: 12, fontFace: "Calibri" });
  });

  // Right column
  s.addShape(pres.ShapeType.rect, { x: 4.9, y: 0.85, w: 4.85, h: 4.55, fill: { color: C.white }, line: { color: C.teal, width: 1 } });
  s.addText("NEUROLOGICAL EXAMINATION", { x: 5.0, y: 0.9, w: 4.6, h: 0.38, fontSize: 13, bold: true, color: C.teal, fontFace: "Calibri" });
  const exam = [
    ["Visual Acuity OD:", "6/60  (↓ from 6/6)"],
    ["Relative Afferent Pupillary Defect:", "Present (RAPD +ve)"],
    ["Fundus:", "Disc pallor OD"],
    ["Motor:", "MRC Grade 3/5 both LL"],
    ["Tone:", "Spasticity both LL (↑)"],
    ["Reflexes:", "Hyperreflexia + Babinski +ve"],
    ["Sensory:", "Reduced vibration below T10"],
    ["Cerebellar:", "Ataxia, dysdiadochokinesia"],
    ["Lhermitte's Sign:", "Positive"],
  ];
  exam.forEach((item, i) => {
    s.addText([
      { text: item[0] + " ", options: { bold: true, color: C.navy } },
      { text: item[1], options: { color: C.text } },
    ], { x: 5.05, y: 1.38 + i * 0.38, w: 4.55, h: 0.35, fontSize: 11, fontFace: "Calibri" });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 5 — INVESTIGATIONS & MRI (with image)
// ═══════════════════════════════════════════════════════
{
  let s = pres.addSlide();
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  s.addText("INVESTIGATIONS", {
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    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 2,
  });

  // left column — labs
  const labRows = [
    ["MRI Brain (FLAIR):", "Periventricular T2 hyperintensities,\nDawson's fingers, juxtacortical lesions"],
    ["MRI Cervical Spine:", "Multiple intramedullary T2 lesions\n(C3-C5, C7-T1)"],
    ["Gd-Enhancement:", "Active right frontal lesion"],
    ["CSF Analysis:", "Oligoclonal IgG bands (positive),\nIgG index elevated"],
    ["VEP:", "Prolonged P100 latency bilaterally\n(right > left)"],
    ["CBC / Metabolic Panel:", "Within normal limits"],
    ["ANA / ANCA:", "Negative (to exclude lupus, vasculitis)"],
    ["NMO-IgG (AQP4):", "Negative"],
  ];
  labRows.forEach((row, i) => {
    const y = 0.76 + i * 0.56;
    s.addText(row[0], { x: 0.35, y, w: 2.6, h: 0.5, fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", valign: "middle" });
    s.addText(row[1], { x: 2.95, y, w: 3.2, h: 0.5, fontSize: 11, color: C.white, fontFace: "Calibri", valign: "middle" });
    if (i < labRows.length - 1)
      s.addShape(pres.ShapeType.line, { x: 0.35, y: y + 0.52, w: 6.15, h: 0, line: { color: "2C4A6E", width: 0.75 } });
  });

  // Right — MRI image
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    s.addImage({ data: imgs[0].base64, x: 6.5, y: 0.65, w: 3.25, h: 3.2 });
    s.addText("MRI: Periventricular lesions (Dawson's fingers)\n& cervical cord plaques", {
      x: 6.5, y: 3.88, w: 3.25, h: 0.65,
      fontSize: 9.5, italic: true, color: C.muted, fontFace: "Calibri", align: "center",
    });
  } else {
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    s.addText("MRI Scan\n(Periventricular lesions)", { x: 6.5, y: 0.65, w: 3.25, h: 3.2, fontSize: 13, color: C.muted, align: "center", valign: "middle", fontFace: "Calibri" });
  }
}

// ═══════════════════════════════════════════════════════
// SLIDE 6 — DIAGNOSIS & McDONALD CRITERIA
// ═══════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });

  s.addText("DIAGNOSIS: McDonald Criteria 2017", {
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  });

  // Diagnosis banner
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  s.addText("FINAL DIAGNOSIS: Relapsing-Remitting Multiple Sclerosis (RRMS)", {
    x: 0.35, y: 0.82, w: 9.4, h: 0.72,
    fontSize: 18, bold: true, color: C.gold, fontFace: "Calibri", align: "center", valign: "middle",
  });

  // Two criteria boxes
  const left = [
    ["Dissemination in Space (DIS)", [
      "≥2 lesion locations: periventricular, juxtacortical,",
      "infratentorial, spinal cord",
      "✔ Periventricular lesions (Dawson's fingers)",
      "✔ Juxtacortical lesion",
      "✔ Cervical cord lesions (C3–C5, C7–T1)",
      "✔ Optic nerve involvement",
    ]],
  ];
  const right = [
    ["Dissemination in Time (DIT)", [
      "≥2 attacks separated in time OR",
      "simultaneous Gd+ & T2 lesions",
      "✔ First attack: diplopia 2 years ago",
      "✔ Second attack: ataxia 6 months ago",
      "✔ Current attack: optic neuritis",
      "✔ Active Gd-enhancing lesion on MRI",
    ]],
  ];

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    cols.forEach(([title, items]) => {
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      s.addText(title, { x: xStart + 0.1, y: 1.65, w: 4.35, h: 0.48, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
      items.forEach((item, i) => {
        const isCheck = item.startsWith("✔");
        s.addText(item, {
          x: xStart + 0.2, y: 2.2 + i * 0.44, w: 4.2, h: 0.4,
          fontSize: 11.5, color: isCheck ? C.green : C.text,
          bold: isCheck, fontFace: "Calibri",
        });
      });
    });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 7 — DISEASE SUBTYPES & EPIDEMIOLOGY
// ═══════════════════════════════════════════════════════
{
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });

  s.addText("MS — DISEASE OVERVIEW & EPIDEMIOLOGY", {
    x: 0.35, y: 0.1, w: 9.4, h: 0.52,
    fontSize: 21, bold: true, color: C.white, fontFace: "Calibri",
  });

  // Epidemiology stats row
  const stats = [
    { val: "2.9M+", lbl: "People with MS\nWorldwide" },
    { val: "F:M 2:1", lbl: "Female Predomi-\nnance" },
    { val: "20–40 yr", lbl: "Typical Age\nat Onset" },
    { val: "85%", lbl: "Initially\nRRMS" },
  ];
  stats.forEach((st, i) => {
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    s.addText(st.lbl, { x, y: 1.38, w: 2.2, h: 0.5, fontSize: 10, color: C.white, fontFace: "Calibri", align: "center" });
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  // Subtypes
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  const subtypes = [
    { name: "RRMS", color: C.teal, desc: "85% of cases. Distinct relapses with full/partial recovery. Our patient." },
    { name: "SPMS", color: C.navy, desc: "Gradual progression after initial relapsing course. Disability accumulates." },
    { name: "PPMS", color: C.red, desc: "15% of cases. Steady worsening from onset without relapses. Male-predominant." },
    { name: "CIS", color: C.green, desc: "First demyelinating episode. Not yet classified as MS until 2nd attack." },
  ];
  subtypes.forEach((sub, i) => {
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    s.addText(sub.desc, { x: x + 1.1, y: y + 0.18, w: 3.35, h: 0.85, fontSize: 11.5, color: C.text, fontFace: "Calibri" });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 8 — PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════
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    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri", charSpacing: 2,
  });

  // Flow arrow chain
  const steps = [
    { icon: "①", head: "Genetic Predisposition", body: "HLA-DR2 / HLA-DRB1*1501\n+ environmental triggers" },
    { icon: "②", head: "Peripheral Sensitization", body: "Autoreactive T-cells against\nmyelin basic protein (MBP)" },
    { icon: "③", head: "BBB Breakdown", body: "T-cells cross blood–brain barrier;\nlocal inflammation & cytokines" },
    { icon: "④", head: "Demyelination & Plaque", body: "Oligodendrocyte damage;\naxonal conduction failure" },
    { icon: "⑤", head: "Neurodegeneration", body: "Progressive axonal loss;\nirreversible disability" },
  ];

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    s.addShape(pres.ShapeType.rect, { x, y: 0.78, w: 1.78, h: 0.55, fill: { color: C.teal } });
    s.addText(step.icon, { x, y: 0.78, w: 1.78, h: 0.55, fontSize: 18, bold: true, color: C.white, align: "center", valign: "middle", fontFace: "Calibri" });
    s.addText(step.head, { x: x + 0.08, y: 1.42, w: 1.62, h: 0.7, fontSize: 11, bold: true, color: C.gold, fontFace: "Calibri", align: "center" });
    s.addText(step.body, { x: x + 0.08, y: 2.18, w: 1.62, h: 2.3, fontSize: 10.5, color: C.white, fontFace: "Calibri", align: "center" });
    if (i < steps.length - 1) {
      s.addShape(pres.ShapeType.line, { x: x + 1.78, y: 1.42, w: 0.12, h: 0, line: { color: C.gold, width: 2 } });
    }
  });

  // Key features bottom
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 4.72, w: 9.4, h: 0.72, fill: { color: "0F1F38" } });
  s.addText([
    { text: "Key targets: ", options: { bold: true, color: C.gold } },
    { text: "Myelin (CNS) • Oligodendrocytes • Axons | Hallmark: Multifocal demyelinated plaques — periventricular, optic nerves, brainstem, spinal cord, cerebellum", options: { color: C.white } },
  ], { x: 0.5, y: 4.72, w: 9.1, h: 0.72, fontSize: 11.5, fontFace: "Calibri", valign: "middle" });
}

// ═══════════════════════════════════════════════════════
// SLIDE 9 — MRI FINDINGS (with image)
// ═══════════════════════════════════════════════════════
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  s.addText("MRI FINDINGS IN THIS CASE", {
    x: 0.35, y: 0.1, w: 9.4, h: 0.52,
    fontSize: 24, bold: true, color: C.white, fontFace: "Calibri",
  });

  if (imgs[1] && !imgs[1].error) {
    s.addImage({ data: imgs[1].base64, x: 0.35, y: 0.72, w: 5.5, h: 4.6 });
  } else {
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    s.addText("MRI Image", { x: 0.35, y: 0.72, w: 5.5, h: 4.6, fontSize: 18, color: C.muted, align: "center", valign: "middle", fontFace: "Calibri" });
  }

  const findings = [
    ["FLAIR/T2:", "Multiple periventricular hyperintense ovoid lesions perpendicular to ventricles ("Dawson's fingers")"],
    ["Juxtacortical:", "Lesion in left inferior temporal lobe"],
    ["Infratentorial:", "Lesion in pons/cerebellum"],
    ["Spinal Cord:", "Intramedullary lesions at C3–C5 & C7–T1"],
    ["T1 Gd+:", "Active right frontal enhancing lesion → blood–brain barrier breakdown"],
    ["DIT + DIS:", "Fulfilled → confirms McDonald 2017 criteria"],
  ];

  findings.forEach((row, i) => {
    s.addText([
      { text: row[0] + " ", options: { bold: true, color: C.gold } },
      { text: row[1], options: { color: C.white } },
    ], { x: 6.0, y: 0.82 + i * 0.72, w: 3.75, h: 0.64, fontSize: 11, fontFace: "Calibri", valign: "middle" });
    if (i < findings.length - 1)
      s.addShape(pres.ShapeType.line, { x: 6.0, y: 0.82 + (i + 1) * 0.72 - 0.04, w: 3.75, h: 0, line: { color: "2C4A6E", width: 0.75 } });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 10 — DISABILITY ASSESSMENT (EDSS)
// ═══════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightbg } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.navy } });
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  s.addText("FUNCTIONAL STATUS & DISABILITY ASSESSMENT", {
    x: 0.35, y: 0.1, w: 9.4, h: 0.52,
    fontSize: 20, bold: true, color: C.white, fontFace: "Calibri",
  });

  // EDSS score
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  s.addText("EDSS Score", { x: 0.35, y: 0.82, w: 3.5, h: 0.5, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", align: "center" });
  s.addText("4.5", { x: 0.35, y: 1.22, w: 3.5, h: 1.0, fontSize: 52, bold: true, color: C.gold, fontFace: "Calibri", align: "center" });
  s.addText("Moderate Disability", { x: 0.35, y: 2.22, w: 3.5, h: 0.38, fontSize: 12, color: C.white, fontFace: "Calibri", align: "center" });

  s.addText("Expanded Disability Status Scale (EDSS) — Kurtzke", {
    x: 0.35, y: 2.7, w: 3.5, h: 0.35, fontSize: 9.5, italic: true, color: C.muted, fontFace: "Calibri", align: "center",
  });

  // Functional systems
  const fs = [
    { name: "Pyramidal", score: 3, max: 6, note: "Mild-moderate paraparesis LL" },
    { name: "Sensory", score: 3, max: 6, note: "↓ vibration, position sense" },
    { name: "Visual", score: 3, max: 6, note: "Optic neuritis OD" },
    { name: "Cerebellar", score: 2, max: 5, note: "Mild ataxia" },
    { name: "Bladder/Bowel", score: 2, max: 6, note: "Urgency/hesitancy" },
    { name: "Brainstem", score: 1, max: 5, note: "Subtle signs" },
    { name: "Cerebral", score: 1, max: 5, note: "Mild fatigue/mood" },
  ];

  s.addText("Functional System Scores", { x: 4.1, y: 0.82, w: 5.65, h: 0.38, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  fs.forEach((f, i) => {
    const y = 1.28 + i * 0.54;
    const barW = (f.score / f.max) * 3.5;
    s.addText(f.name, { x: 4.1, y, w: 1.55, h: 0.38, fontSize: 11, color: C.text, fontFace: "Calibri", bold: true });
    s.addShape(pres.ShapeType.rect, { x: 5.7, y: y + 0.06, w: 3.5, h: 0.26, fill: { color: "D6E8F5" } });
    s.addShape(pres.ShapeType.rect, { x: 5.7, y: y + 0.06, w: barW, h: 0.26, fill: { color: C.teal } });
    s.addText(`${f.score}/${f.max}`, { x: 9.25, y, w: 0.5, h: 0.38, fontSize: 11, bold: true, color: C.navy, fontFace: "Calibri" });
    s.addText(f.note, { x: 4.1, y: y + 0.34, w: 5.65, h: 0.18, fontSize: 9, italic: true, color: C.muted, fontFace: "Calibri" });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 11 — MEDICAL MANAGEMENT
// ═══════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.teal } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });

  s.addText("MEDICAL MANAGEMENT", {
    x: 0.35, y: 0.1, w: 9.4, h: 0.52,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
  });

  const sections = [
    {
      title: "Acute Relapse Treatment", color: C.red, x: 0.35, y: 0.82, items: [
        "IV Methylprednisolone 1g/day × 5 days",
        "Shortens relapse duration (not long-term disability)",
        "Consider plasma exchange if steroid-refractory",
      ]
    },
    {
      title: "Disease-Modifying Therapy (DMT)", color: C.navy, x: 5.05, y: 0.82, items: [
        "High-efficacy preferred for active RRMS",
        "Natalizumab (anti-VLA-4) — preferred (high activity)",
        "Alternatives: Ocrelizumab, Alemtuzumab",
        "First-line: IFN-β, Glatiramer, Teriflunomide",
      ]
    },
    {
      title: "Symptomatic Management", color: C.teal, x: 0.35, y: 2.68, items: [
        "Spasticity: Baclofen 5–20 mg TID, Tizanidine",
        "Fatigue: Amantadine 100 mg BD, exercise",
        "Bladder: Oxybutynin / CIC as needed",
        "Pain/Lhermitte's: Carbamazepine, Gabapentin",
        "Depression: SSRIs, CBT",
        "Pseudobulbar affect: Dextromethorphan/Quinidine",
      ]
    },
    {
      title: "Neuroprotection & Monitoring", color: C.green, x: 5.05, y: 2.68, items: [
        "Vitamin D supplementation (target >50 ng/mL)",
        "Annual brain MRI to monitor lesion burden",
        "EDSS reassessment every 6 months",
        "Ophthalmology follow-up for optic neuritis",
      ]
    },
  ];

  sections.forEach(sec => {
    s.addShape(pres.ShapeType.rect, { x: sec.x, y: sec.y, w: 4.55, h: 2.6, fill: { color: C.white }, line: { color: sec.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x: sec.x, y: sec.y, w: 4.55, h: 0.44, fill: { color: sec.color } });
    s.addText(sec.title, { x: sec.x + 0.1, y: sec.y, w: 4.35, h: 0.44, fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    sec.items.forEach((item, i) => {
      s.addText([{ text: "▸ ", options: { color: sec.color, bold: true } }, { text: item, options: { color: C.text } }],
        { x: sec.x + 0.12, y: sec.y + 0.52 + i * 0.43, w: 4.28, h: 0.4, fontSize: 11, fontFace: "Calibri" });
    });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 12 — PM&R REHABILITATION GOALS
// ═══════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });

  s.addText("PM&R REHABILITATION GOALS", {
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    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
  });

  s.addText("Comprehensive rehabilitation addresses physical, cognitive, and psychosocial dimensions", {
    x: 0.35, y: 0.8, w: 9.4, h: 0.4,
    fontSize: 12, italic: true, color: C.teal, fontFace: "Calibri",
  });

  const goals = [
    { icon: "🦵", domain: "Motor", items: ["Improve lower limb strength (target MRC 4/5)", "Reduce spasticity & contracture risk", "Restore gait pattern & balance", "Prevent falls & injury"] },
    { icon: "🧠", domain: "Cognitive", items: ["Address fatigue management strategies", "Cognitive retraining for attention/memory", "Vocational rehabilitation assessment", "Return to work planning"] },
    { icon: "🚽", domain: "Bladder/Bowel", items: ["Bladder retraining program", "Timed voiding schedule", "CIC teaching if indicated", "Bowel program & dietary advice"] },
    { icon: "❤️", domain: "Quality of Life", items: ["Psychological support & counseling", "ADL training & adaptive equipment", "Social & community reintegration", "Patient & family education"] },
  ];

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    const y = 1.28 + Math.floor(i / 2) * 2.1;
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    s.addShape(pres.ShapeType.rect, { x, y, w: 0.7, h: 1.95, fill: { color: i % 2 === 0 ? C.navy : C.teal } });
    s.addText(goal.domain, { x, y: y + 0.05, w: 0.7, h: 1.85, fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle" });
    goal.items.forEach((item, j) => {
      s.addText([{ text: "• ", options: { color: C.gold, bold: true } }, { text: item, options: { color: C.text } }],
        { x: x + 0.78, y: y + 0.12 + j * 0.43, w: 3.65, h: 0.4, fontSize: 11, fontFace: "Calibri" });
    });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 13 — REHABILITATION INTERVENTIONS
// ═══════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.dark } });
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  s.addText("REHABILITATION INTERVENTIONS", {
    x: 0.35, y: 0.1, w: 5.6, h: 0.52,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
  });

  const interventions = [
    { title: "Physiotherapy", color: C.teal, items: ["Stretching & ROM exercises for spasticity", "Progressive resistance training", "Gait training with AFO if foot drop", "Balance & proprioception training", "Frenkel's exercises for ataxia"] },
    { title: "Occupational Therapy", color: C.gold, items: ["ADL training & adaptive equipment", "Energy conservation techniques", "Upper limb fine motor training", "Home modification assessment", "Driving rehabilitation evaluation"] },
    { title: "Speech & Swallowing", color: C.navy, items: ["Dysarthria therapy if present", "Dysphagia assessment (VFSS)", "Communication aids if needed"] },
    { title: "Neuromodulation", color: C.red, items: ["Transcutaneous electrical stimulation", "Functional electrical stimulation (FES)", "Transcranial magnetic stimulation (rTMS)", "Intrathecal baclofen if severe spasticity"] },
  ];

  interventions.forEach((iv, i) => {
    const x = 0.35 + (i % 2) * 4.75;
    const y = 0.75 + Math.floor(i / 2) * 2.3;
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.55, h: 2.15, fill: { color: "0F1F38" }, line: { color: iv.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x, y, w: 4.55, h: 0.44, fill: { color: iv.color } });
    s.addText(iv.title, { x: x + 0.1, y, w: 4.35, h: 0.44, fontSize: 13, bold: true, color: C.white, fontFace: "Calibri", valign: "middle" });
    iv.items.forEach((item, j) => {
      s.addText([{ text: "▸ ", options: { color: iv.color, bold: true } }, { text: item, options: { color: C.white } }],
        { x: x + 0.15, y: y + 0.52 + j * 0.33, w: 4.25, h: 0.3, fontSize: 10.5, fontFace: "Calibri" });
    });
  });

  // Rehab image
  if (imgs[2] && !imgs[2].error) {
    s.addImage({ data: imgs[2].base64, x: 9.1 - 0.5, y: 0.62, w: 0.95, h: 4.75 });
  }
}

// ═══════════════════════════════════════════════════════
// SLIDE 14 — MULTIDISCIPLINARY TEAM & OUTCOME
// ═══════════════════════════════════════════════════════
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  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.lightbg } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 0.72, fill: { color: C.teal } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.18, h: 5.625, fill: { color: C.gold } });

  s.addText("MDT APPROACH & FUNCTIONAL OUTCOME", {
    x: 0.35, y: 0.1, w: 9.4, h: 0.52,
    fontSize: 22, bold: true, color: C.white, fontFace: "Calibri",
  });

  // MDT wheel - central text + spokes
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  const members = [
    { role: "Physiatrist", x: 0.35, y: 0.95 },
    { role: "Physiotherapist", x: 0.35, y: 1.8 },
    { role: "Occupational\nTherapist", x: 0.35, y: 2.7 },
    { role: "Neurologist", x: 7.05, y: 0.95 },
    { role: "Urologist /\nContinence Nurse", x: 7.05, y: 1.8 },
    { role: "Psychologist /\nSocial Worker", x: 7.05, y: 2.7 },
  ];
  members.forEach((m) => {
    s.addShape(pres.ShapeType.rect, { x: m.x, y: m.y, w: 2.9, h: 0.65, fill: { color: C.white }, line: { color: C.teal, width: 1 } });
    s.addText(m.role, { x: m.x + 0.1, y: m.y, w: 2.7, h: 0.65, fontSize: 12, color: C.navy, fontFace: "Calibri", bold: true, valign: "middle", align: "center" });
  });

  // Outcome
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  s.addText("PATIENT OUTCOME AT 6 MONTHS", { x: 0.45, y: 3.67, w: 9.2, h: 0.4, fontSize: 13, bold: true, color: C.navy, fontFace: "Calibri" });
  const outcomes = [
    "EDSS improved from 4.5 → 3.0 (ambulatory without aid)",
    "Visual acuity OD recovered to 6/18 following optic neuritis treatment",
    "Lower limb strength improved to MRC 4/5 bilaterally",
    "Bladder symptoms controlled with timed voiding + anticholinergic therapy",
    "Returned to part-time work; enrolled in natalizumab therapy",
  ];
  outcomes.forEach((oc, i) => {
    s.addText([{ text: "✔ ", options: { color: C.green, bold: true } }, { text: oc, options: { color: C.text } }],
      { x: 0.5, y: 4.12 + i * 0.24, w: 9.1, h: 0.22, fontSize: 11, fontFace: "Calibri" });
  });
}

// ═══════════════════════════════════════════════════════
// SLIDE 15 — SUMMARY & KEY MESSAGES
// ═══════════════════════════════════════════════════════
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  s.addText("SUMMARY & TAKE-HOME MESSAGES", {
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    fontSize: 22, bold: true, color: C.gold, fontFace: "Calibri",
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  const messages = [
    { num: "01", msg: "MS is the leading cause of non-traumatic neurological disability in young adults — females > males (2:1)." },
    { num: "02", msg: "McDonald 2017 criteria require Dissemination in Space AND Time — MRI is the cornerstone of diagnosis." },
    { num: "03", msg: "RRMS (85%) presents with relapses; Optic neuritis + sensorimotor deficits in young females should prompt urgent workup." },
    { num: "04", msg: "Early high-efficacy DMT (Natalizumab/Ocrelizumab) significantly reduces relapse rate and disability accumulation." },
    { num: "05", msg: "PM&R plays a critical role: MDT rehabilitation improves function, independence, and quality of life across the disease course." },
    { num: "06", msg: "EDSS monitoring, bladder care, spasticity management, and psychosocial support are essential PM&R components." },
  ];

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    s.addText(m.msg, { x: 1.08, y, w: 8.55, h: 0.7, fontSize: 12.5, color: C.white, fontFace: "Calibri", valign: "middle" });
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      s.addShape(pres.ShapeType.line, { x: 0.35, y: y + 0.76, w: 9.3, h: 0, line: { color: "1B3A6B", width: 0.75 } });
  });
}

// ─── Write file ───────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/ms-presentation/Multiple_Sclerosis_CasePresentation_PMR.pptx" })
  .then(() => console.log("DONE"))
  .catch(err => console.error("ERROR:", err));

cd /home/daytona/workspace/ms-presentation && node create_ms_pptx.js 2>&1