ls /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/bibr…

~/bibrachial-mnd-ppt/generate.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Bibrachial MND (Flail Arm Syndrome)";
pres.author = "Archibald / Adams & Victor Neurology";

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// ═══════════════════════════════════════════════════════════════
//  SLIDE 1 — TITLE
// ═══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  titleSlide(s,
    "Bibrachial MND\n(Flail Arm Syndrome)",
    "Motor Neuron Disease — Proximal & Distal Patterns | Differential Diagnosis | Clinical Features | Investigations"
  );
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 2 — OVERVIEW / DEFINITION
// ═══════════════════════════════════════════════════════════════
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  contentSlide(s, "What is Bibrachial MND?", [
    "Bibrachial MND (Flail Arm Syndrome / Dangling Arm Syndrome) is a segmental variant of ALS",
    "Selective involvement of BOTH upper limbs with weakness, wasting and fasciculations",
    "Represents ~5-10% of all ALS cases",
    "Strongly male predominant (even stronger than typical ALS; M:F ratio ~9:1)",
    "Associated with a LONGER median survival compared to classic ALS",
    "First described as a distinct clinical entity — also called 'Man-in-a-Barrel' syndrome when due to bilateral watershed infarcts",
    "In the MND context — reflects selective degeneration of anterior horn cells at C5-T1 segments",
    "Progression to bulbar or leg involvement is typically late and slow",
  ], { ref: "Adams & Victor's Principles of Neurology, 12e, p.1389 | Goldman-Cecil Medicine, Table 387" });
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 3 — SECTION HEADER: PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════════
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  sectionHeader(s, "Pathophysiology &\nMechanism of Occurrence", "How does Bibrachial MND occur?");
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 4 — PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════════
{
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  contentSlide(s, "Pathophysiology — Mechanism of Bibrachial MND", [
    "Selective degeneration of lower motor neurons (anterior horn cells) in the CERVICAL spinal cord (C5–T1)",
    "Both UMN (corticospinal) and LMN (anterior horn) pathways are affected in ALS, but in Flail Arm Syndrome:",
    "  LMN degeneration is dominant in the cervical cord",
    "  UMN signs are subtle or minimal initially",
    "Disproportionate vulnerability of the cervical ventral horn compared to lumbar or bulbar motor neurons",
    "Neurofilament accumulation, TDP-43 proteinopathy, and SOD1 mutations contribute to selective AHC death",
    "The corticospinal tract degeneration is less prominent — explaining relative sparing of legs",
    "Axonal transport failure leads to muscle denervation → atrophy → fasciculations",
    "Progressive spread rostral/caudal is slower than classic ALS — hence better prognosis",
  ], { ref: "Adams & Victor's Principles of Neurology, 12e | Goldman-Cecil Medicine, 2 Vol Set" });
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 5 — SECTION HEADER: PROXIMAL vs DISTAL
// ═══════════════════════════════════════════════════════════════
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  sectionHeader(s, "Proximal vs Distal Patterns", "Distribution of weakness in Bibrachial MND");
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 6 — PROXIMAL vs DISTAL TWO COLUMN
// ═══════════════════════════════════════════════════════════════
{
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  twoColSlide(
    s,
    "Proximal vs Distal Involvement in Bibrachial MND",
    "PROXIMAL Pattern",
    [
      "Muscles: Deltoid, supraspinatus, infraspinatus, biceps, triceps, shoulder girdle",
      "Predominant in Flail Arm Syndrome — inability to raise arms above head",
      "Arms hang limply at sides ('dangling arms')",
      "Preserved grip strength initially — hands and forearms spared early",
      "Clinical sign: Man-in-a-barrel posture",
      "Suggests C5-C6 AHC predominant involvement",
      "Compared with ALS: FAS has predilection for PROXIMAL UE muscles without significant leg weakness",
      "Scapular winging may be seen",
    ],
    "DISTAL Pattern",
    [
      "Muscles: Intrinsic hand muscles, thenar, hypothenar, wrist extensors/flexors",
      "Split-hand sign: wasting of thenar + 1st dorsal interosseous with relative hypothenar sparing",
      "Suggests C8–T1 AHC involvement",
      "More typical in classic ALS presentation — distal > proximal",
      "Weakness of grip, pinch, fine finger movements",
      "Progresses to involve forearm muscles",
      "In pure LMN form (PMA): distal hand wasting may predominate",
      "EMG shows active denervation in intrinsic hand muscles earliest",
    ],
    "Adams & Victor's Principles of Neurology, 12e, p.1389 | Frameworks for Internal Medicine | Goldman-Cecil Medicine"
  );
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 7 — CLINICAL FEATURES
// ═══════════════════════════════════════════════════════════════
{
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  sectionHeader(s, "Clinical Features", "Signs & Symptoms of Bibrachial MND");
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 8 — CLINICAL FEATURES CONTENT
// ═══════════════════════════════════════════════════════════════
{
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  contentSlide(s, "Clinical Features of Flail Arm Syndrome (Bibrachial MND)", [
    "ONSET: Insidious, usually after age 45; mean age ~55-65 years; male predominance (9:1)",
    "WEAKNESS: Progressive bilateral proximal arm weakness — inability to raise arms, abduct shoulders",
    "WASTING: Prominent muscle atrophy of upper arms, shoulders, forearms and hands",
    "FASCICULATIONS: Visible spontaneous muscle twitching in affected muscles",
    "TONE: Reduced tone in upper limbs (LMN) — may have subtle hyperreflexia if UMN involved",
    "REFLEXES: Biceps and brachioradialis reflexes lost; finger jerks absent; triceps may be paradoxically brisk (UMN sign)",
    "SENSORY: COMPLETELY NORMAL — no sensory loss (purely motor syndrome)",
    "LEGS: Spared initially; subtle UMN signs may develop later (brisk knee/ankle jerks, extensor plantar)",
    "BULBAR: Usually spared early; dysarthria/dysphagia appear late if disease spreads",
    "RESPIRATORY: Diaphragm may be involved late; FVC monitoring essential",
    "No sphincter involvement; eye movements normal throughout disease course",
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}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 9 — DIFFERENTIAL DIAGNOSIS (SECTION)
// ═══════════════════════════════════════════════════════════════
{
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  sectionHeader(s, "Differential Diagnosis", "Conditions mimicking Bibrachial MND / Flail Arm Syndrome");
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 10 — DD TABLE (part 1)
// ═══════════════════════════════════════════════════════════════
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      { text: "Mixed UMN + LMN; involves ALL 4 limbs + bulbar; faster progression; distal > proximal in limbs", options: {} },
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    [
      { text: "Progressive Muscular Atrophy (PMA)", options: {} },
      { text: "Pure LMN; no UMN signs; more distal; slower progression; 5-yr survival ~70% if onset <50 yrs", options: {} },
      { text: "No", options: { color: C.green } },
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    [
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      { text: "Asymmetric; conduction block on NCS; anti-GM1 antibodies 50-60%; responds to IVIG", options: {} },
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    [
      { text: "Parsonage-Turner / Brachial Neuritis", options: {} },
      { text: "Acute severe pain precedes weakness; unilateral or bilateral; self-limiting; idiopathic/postinfectious", options: {} },
      { text: "Yes", options: { color: C.red, bold: true } },
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// ═══════════════════════════════════════════════════════════════
//  SLIDE 11 — DD TABLE (part 2)
// ═══════════════════════════════════════════════════════════════
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      { text: "Inclusion Body Myositis (IBM)", options: {} },
      { text: "Finger flexor + quadriceps wasting; CK elevated; muscle biopsy shows rimmed vacuoles; no fasciculations", options: {} },
      { text: "No", options: { color: C.green } },
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      { text: "Facioscapulohumeral Dystrophy", options: {} },
      { text: "Face + shoulder girdle weakness; family history; CK mildly elevated; gene deletion chromosome 4q35", options: {} },
      { text: "No", options: { color: C.green } },
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      { text: "Kennedy Disease (SBMA)", options: {} },
      { text: "X-linked; gynecomastia; perioral fasciculations; sensory involvement on NCS; CAG repeat (AR gene)", options: {} },
      { text: "Yes (NCS)", options: { color: C.red } },
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    [
      { text: "Polymyositis", options: {} },
      { text: "Proximal weakness; elevated CK; muscle tenderness; responds to steroids; EMG myopathic pattern", options: {} },
      { text: "No", options: { color: C.green } },
    ],
    [
      { text: "Paraneoplastic Motor Neuropathy", options: {} },
      { text: "Underlying malignancy; may have sensory component; anti-neuronal antibodies (anti-Hu, etc.)", options: {} },
      { text: "Possible", options: { color: C.gold } },
    ],
    [
      { text: "Amyloid Neuropathy", options: {} },
      { text: "Systemic features; sensory + autonomic dysfunction; monoclonal protein; nerve biopsy", options: {} },
      { text: "Yes", options: { color: C.red, bold: true } },
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    [
      { text: "Post-Polio Syndrome", options: {} },
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// ═══════════════════════════════════════════════════════════════
//  SLIDE 12 — INVESTIGATIONS (SECTION)
// ═══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionHeader(s, "Investigations", "Diagnostic Workup for Bibrachial MND");
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 13 — INVESTIGATIONS CONTENT
// ═══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Investigations in Bibrachial MND / Flail Arm Syndrome", [
    "ELECTROMYOGRAPHY (EMG) — CORNERSTONE OF DIAGNOSIS:",
    "  Active denervation: fibrillation potentials, positive sharp waves in cervical myotomes",
    "  Fasciculation potentials — pathological in context of weakness",
    "  Chronic reinnervation: large amplitude, long duration, polyphasic motor units",
    "  Awaji-Shima criteria: LMN signs in ≥2 muscles (different roots/nerves) in cervical region",
    "NERVE CONDUCTION STUDIES (NCS):",
    "  Motor conduction velocities — usually normal (axonal loss pattern)",
    "  Sensory nerve action potentials (SNAPs) — NORMAL (key to distinguish from MMN/CIDP)",
    "  No conduction block (rules out MMN)",
    "MRI BRAIN & CERVICAL SPINE:",
    "  Rule out structural causes (disc disease, cord compression, syrinx)",
    "  MRI brain: may show T2 hyperintensity of corticospinal tract in ALS",
  ], { fontSize: 13.5, ref: "Goldman-Cecil Medicine | Adams & Victor, 12e | Awaji-Shima Criteria" });
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 14 — INVESTIGATIONS (BLOOD TESTS)
// ═══════════════════════════════════════════════════════════════
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  twoColSlide(
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    "Investigations — Blood Tests & Ancillary Studies",
    "BLOOD TESTS",
    [
      "FBC, serum electrolytes, calcium",
      "Thyroid function (TFTs) — rule out thyrotoxic myopathy",
      "CK level: mildly elevated in MND (but not as high as myopathy)",
      "Serum protein electrophoresis (paraprotein?)",
      "Anti-GM1 ganglioside antibodies — exclude MMN",
      "Anti-MAG antibodies — paraprotein neuropathy",
      "ESR, CRP — inflammatory causes",
      "Acetylcholine receptor Abs — rule out MG",
      "Hexosaminidase A/B — adult Tay-Sachs",
      "HIV serology",
      "Heavy metal screen (lead), urinary porphyrins",
      "Genetic testing: SOD1, C9ORF72 if familial",
    ],
    "ANCILLARY INVESTIGATIONS",
    [
      "CSF analysis: protein (elevated in CIDP, normal in ALS)",
      "Pulmonary Function Tests (FVC): baseline respiratory assessment — vital for management",
      "Muscle biopsy: only if diagnostic uncertainty; shows neurogenic atrophy in ALS",
      "Nerve biopsy: not routinely needed; consider if amyloid/vasculitis suspected",
      "Kennedy disease: CAG repeat expansion in androgen receptor gene (if gynecomastia, XL family hx)",
      "PET/CT or body CT: rule out paraneoplastic syndrome if anti-neuronal Abs positive",
      "Neurofilament light chain (NfL): elevated in ALS — promising biomarker (CSF and plasma)",
    ],
    "Goldman-Cecil Medicine | Adams & Victor, 12e | Bradley & Daroff's Neurology in Clinical Practice"
  );
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 15 — DIAGNOSTIC CRITERIA
// ═══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Diagnostic Criteria — Awaji-Shima Consensus (Revised El Escorial)", [
    "DIAGNOSIS OF ALS REQUIRES (all 3):",
    "  1. Evidence of LOWER MOTOR NEURON (LMN) degeneration — clinical or electrophysiologic",
    "  2. Evidence of UPPER MOTOR NEURON (UMN) degeneration — clinical examination",
    "  3. Progressive spread of symptoms/signs within or across body regions",
    "REGIONS: Bulbar | Cervical | Thoracic | Lumbosacral",
    "CLINICALLY DEFINITE ALS: LMN + UMN signs in bulbar + ≥2 spinal regions, OR LMN + UMN in ≥3 spinal regions",
    "CLINICALLY PROBABLE ALS: LMN + UMN in ≥2 regions, with UMN signs rostral to LMN",
    "CLINICALLY POSSIBLE ALS: UMN + LMN signs in only 1 region, or UMN signs alone in ≥2 regions",
    "IN FLAIL ARM SYNDROME: LMN signs predominant in cervical region; UMN signs subtle/absent early",
    "KEY EXCLUSIONS: Sensory loss, sphincter dysfunction, autonomic failure, visual impairment, cognitive decline (early)",
  ], { fontSize: 13.5, ref: "Awaji-Shima Consensus Criteria | Goldman-Cecil Medicine Table 387-2 | Adams & Victor, 12e" });
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 16 — PROGNOSIS & MANAGEMENT
// ═══════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  contentSlide(s, "Prognosis & Management Overview", [
    "PROGNOSIS (Flail Arm Syndrome vs Classic ALS):",
    "  FAS: Longer median survival than typical ALS (median ~4-5 years vs ~2-3 years)",
    "  Slower progression; late spread to legs or bulbar region",
    "  FAS males even more male-predominant than classic ALS",
    "DISEASE-MODIFYING THERAPY:",
    "  Riluzole: modestly extends survival; inhibits glutamate excitotoxicity — standard therapy",
    "  Edaravone: anti-oxidant; approved for early-stage ALS",
    "MULTIDISCIPLINARY CARE (ALS specialist centres):",
    "  Neurologist, respiratory therapist, physiotherapist, OT, speech-language therapist, dietitian",
    "  PEG (gastrostomy) for dysphagia when weight loss >10% or swallowing unsafe",
    "  Non-invasive ventilation (NIV/BiPAP): when FVC <50%, or symptoms of nocturnal hypoventilation",
    "  Communication aids, orthotics (wrist splints, arm supports)",
    "Palliative care planning early in the course",
  ], { fontSize: 13, ref: "Goldman-Cecil Medicine | Adams & Victor, 12e | Bradley & Daroff Neurology in Clinical Practice" });
}

// ═══════════════════════════════════════════════════════════════
//  SLIDE 17 — SUMMARY
// ═══════════════════════════════════════════════════════════════
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  s.addText("Summary: Bibrachial MND (Flail Arm Syndrome)", {
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    { text: "DEFINITION: Segmental ALS variant — bilateral upper limb LMN > UMN involvement; male-predominant; better prognosis than classic ALS", options: { bullet: true, color: C.white, fontSize: 14, breakLine: true } },
    { text: "PROXIMAL: Deltoid/shoulder girdle weakness — arms dangle ('man-in-barrel'); suggests C5-C6 AHC", options: { bullet: true, color: C.gold, fontSize: 14, breakLine: true } },
    { text: "DISTAL: Intrinsic hand/thenar wasting — split-hand sign; suggests C8-T1 AHC; typical in classic ALS", options: { bullet: true, color: C.gold, fontSize: 14, breakLine: true } },
    { text: "CLINICAL CLUE: Bilateral arm weakness + fasciculations + NORMAL SENSATION = think bibrachial MND", options: { bullet: true, color: C.light, fontSize: 14, breakLine: true } },
    { text: "KEY DD: MMN (conduction block, GM1 Ab), CIDP (sensory, elevated CSF protein), Cervical myelopathy (sensory level, MRI), Kennedy disease (gynecomastia, CAG repeat)", options: { bullet: true, color: C.white, fontSize: 13.5, breakLine: true } },
    { text: "INVESTIGATIONS: EMG (denervation + reinnervation) + NCS (normal SNAPs, no conduction block) + MRI spine + Blood screen", options: { bullet: true, color: C.light, fontSize: 14, breakLine: true } },
    { text: "CRITERIA: Awaji-Shima / Revised El Escorial for ALS diagnosis", options: { bullet: true, color: C.white, fontSize: 14, breakLine: true } },
    { text: "MANAGEMENT: Riluzole, MDT, NIV, PEG, palliative care", options: { bullet: true, color: C.gold, fontSize: 14, breakLine: false } },
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  s.addText("References: Adams & Victor's Principles of Neurology 12e | Bradley & Daroff's Neurology in Clinical Practice | Goldman-Cecil Medicine | Frameworks for Internal Medicine", {
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// ─── WRITE FILE ─────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/bibrachial-mnd-ppt/Bibrachial_MND_Flail_Arm_Syndrome.pptx" })
  .then(() => console.log("SUCCESS: PPT created"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

cd /home/daytona/workspace/bibrachial-mnd-ppt && node generate.js 2>&1

ls -lh /home/daytona/workspace/bibrachial-mnd-ppt/

ls -lh /home/daytona/workspace/bibrachial-mnd-ppt/ && file /home/daytona/workspa…

cp /home/daytona/workspace/bibrachial-mnd-ppt/Bibrachial_MND_Flail_Arm_Syndrome.…