This disease report and allopathic medicine prescribe by patient

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"chronic lymphocytic leukemia" treatment guidelines

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Disease Report Analysis - Mr. Chiranjee Lal (58 Y/Male)

Report Summary (Peripheral Blood Film - PBF Examination)

Parameter	Finding
RBC	Normocytic hypochromic with mild anisocytosis; few macrocytes; NRBCs 2/100 WBC; no parasites
WBC	Increased (lymphocytosis); DLC: P-05%, L-80%, M-01%, E-00%; few smudge cells; atypical lymphoid cells / ?prolymphocytes 04%
Platelets	Reduced in number, normal morphology (thrombocytopenia)
Impression	Chronic Lymphocytic Leukemia (CLL)
Advice	Immunophenotyping for final confirmation

Diagnosis: Chronic Lymphocytic Leukemia (CLL)

CLL is a mature B-cell malignancy. This report's classic triad - marked lymphocytosis (80%), smudge cells on smear, and thrombocytopenia - is highly characteristic. The atypical lymphoid/?prolymphocyte population at 4% is notable.

What Immunophenotyping Will Confirm

Flow cytometry (immunophenotyping) will look for the CLL-specific pattern:

CD5+, CD19+, CD23+ (co-expression of CD5 with B-cell markers is the hallmark)
Dim surface immunoglobulin (IgM/IgD)
Dim or negative CD20, CD79b
Negative FMC-7

Note: An absolute clonal B-lymphocyte count of ≥5 × 10⁹/L on immunophenotyping is required for a definitive CLL diagnosis.

Allopathic (Modern) Treatment Options

Step 1: Staging First (Before Treatment)

Two staging systems are used:

Rai staging (USA): Stage 0-IV based on lymphocytosis, lymphadenopathy, organomegaly, anemia, thrombocytopenia
Binet staging (Europe): Stage A/B/C

This patient has thrombocytopenia + lymphocytosis - likely Rai Stage III / Binet Stage C (high risk), but formal staging requires clinical exam + CBC values.

Step 2: Treatment Indications (IWCLL Criteria)

Treatment is NOT started in all patients - only when:

Symptomatic disease (B symptoms: fever, night sweats, weight loss)
Progressive marrow failure (worsening anemia/thrombocytopenia)
Massive/progressive splenomegaly or lymphadenopathy
Lymphocyte doubling time < 6 months
Autoimmune hemolytic anemia or ITP not responding to steroids

First-Line Allopathic Medicines (Current 2025-2026 Guidelines)

A. BTK (Bruton Tyrosine Kinase) Inhibitors - PREFERRED FIRST LINE

Drug	Dose	Notes
Ibrutinib (Imbruvica)	420 mg orally once daily, continuous	First-generation; risk of AF, bleeding, hypertension
Acalabrutinib (Calquence)	100 mg orally twice daily, continuous	Better cardiac profile than ibrutinib
Zanubrutinib (Brukinsa)	160 mg orally twice daily, continuous	Most selective; preferred in high-risk patients

The NCCN Guidelines Version 2.2026 (PMID: 41825137) recommend BTK inhibitors as preferred therapy for most patients, regardless of fitness status.

B. BCL2 Inhibitor - Fixed Duration Option

Regimen	Duration	Notes
Venetoclax + Obinutuzumab (VO)	1 year fixed duration	Preferred in older/less fit patients; CLL14 trial: median PFS 76.2 months
Venetoclax + Ibrutinib (IV)	1 year fixed duration	Approved in Europe; GLOW trial data (42-month PFS: 74.6%)

Venetoclax dose: 400 mg/day orally (after 5-week ramp-up to prevent tumor lysis syndrome)
Obinutuzumab: IV infusion, 28-day cycles

C. Chemoimmunotherapy (Older regimen, now less preferred)

Regimen	Notes
FCR (Fludarabine + Cyclophosphamide + Rituximab)	Still used in younger, fit patients with IGHV-mutated CLL; ~20% can achieve very long-term remission
BR (Bendamustine + Rituximab)	For older/less fit patients; less toxic than FCR
Chlorambucil + Obinutuzumab	Elderly/very unfit patients

Supportive / Adjunct Medications

Drug	Purpose
Acyclovir (400 mg BD)	Herpes/viral prophylaxis during active treatment
Cotrimoxazole (TMP-SMX)	PCP prophylaxis if on venetoclax or steroid combinations
Fluconazole / Posaconazole	Antifungal prophylaxis (ECIL 2025 guidelines, PMID: 40200079)
IVIG (intravenous immunoglobulin)	For recurrent infections with hypogammaglobulinemia
Prednisolone	For autoimmune hemolytic anemia (AIHA) or ITP complicating CLL

Monitoring Parameters

CBC every 3-6 months
Watch for tumor lysis syndrome (TLS) with venetoclax
Monitor for cardiac arrhythmias with ibrutinib
Check for Richter's transformation (sudden aggressive lymphoma)

Important Next Steps for This Patient

Immunophenotyping (flow cytometry) - as already advised
FISH cytogenetics - check for del(17p), del(11q), trisomy 12, del(13q) - critical for prognosis and drug choice
IGHV mutational status - unmutated = worse prognosis
CT scan of chest/abdomen/pelvis - full staging
Refer to a haematologist/oncologist - this is a specialist-managed condition

Important Disclaimer: This analysis is for educational purposes only. Actual treatment decisions for Mr. Chiranjee Lal must be made by a qualified haematologist after complete staging workup, including immunophenotyping (as already recommended in the report), FISH cytogenetics, IGHV mutational status, and thorough clinical assessment.

Sources: Harrison's Principles of Internal Medicine 22E (2025); Goldman-Cecil Medicine; NCCN Guidelines CLL/SLL Version 2.2026 (PMID: 41825137); GELLC Spanish CLL Guidelines 2025 (PMID: 39799061)

Generate a clinical reference card showing CLL staging, prognostic markers, and treatment algorithms

Reading File

Running Command

mkdir -p /home/daytona/workspace/cll-reference && ls /home/daytona/workspace/cll-reference/

Writing File

~/cll-reference/cll_card.js

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const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.title = "CLL Clinical Reference Card";
pres.author = "Orris Medical";

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  success: "27AE60",
  warn:    "E67E22",
};

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — Title / Cover
// ═══════════════════════════════════════════════════════════════════════════════
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    { label: "Median Age", value: "70 years" },
    { label: "M:F Ratio", value: "2 : 1" },
    { label: "5-yr Survival", value: "~92%" },
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — Diagnosis & Staging
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  // ── RAI STAGING ──────────────────────────────────────────────────────────────
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  // ── DIAGNOSTIC CRITERIA ──────────────────────────────────────────────────────
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  const diagCrit = [
    "Clonal B-lymphocytes ≥ 5 × 10⁹/L in peripheral blood",
    "Monoclonal B-cell lymphocytosis with CLL immunophenotype",
    "Immunophenotype: CD5+, CD19+, CD23+, dim CD20, dim sIg",
    "Smudge (smear) cells on peripheral blood film",
    "< 55% prolymphocytes (>55% = B-PLL, different entity)",
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// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — Prognostic Markers
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  // ── FISH CYTOGENETICS ─────────────────────────────────────────────────────────
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  // ── OTHER MARKERS ─────────────────────────────────────────────────────────────
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    { title: "β2-Microglobulin", good: "< 3.5 mg/L", bad: "> 3.5 mg/L", impact: "Independent poor prognosis marker", color: C.orange },
    { title: "Serum TK1", good: "Low", bad: "Elevated", impact: "Rapid disease progression predictor", color: C.gold },
    { title: "Lymphocyte DT", good: "> 12 months", bad: "< 6 months", impact: "Treatment trigger if < 6 months", color: C.gold },
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    s.addText("Adverse: " + m.bad, { x: mx + 0.1, y: 5.82, w: 2.8, h: 0.36,
      fontSize: 8, color: C.red });
    s.addShape(pres.ShapeType.rect, { x: mx + 0.05, y: 6.22, w: 2.9, h: 0.04,
      fill: { color: C.midBlue } });
    s.addText(m.impact, { x: mx + 0.1, y: 6.28, w: 2.8, h: 0.7,
      fontSize: 7.5, color: C.muted, italic: true });
  });

  // CLL-IPI note
  s.addText("CLL-IPI Score integrates: IGHV status + TP53 status + β2-microglobulin + clinical stage + age → Stratifies into Low / Intermediate / High / Very High risk", {
    x: 0.45, y: 7.1, w: 12.7, h: 0.34,
    fontSize: 7.5, color: C.gold, italic: true
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — Treatment Algorithm
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 7.5, fill: { color: C.green } });

  // Title bar
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0, w: 12.95, h: 0.72, fill: { color: C.panel } });
  s.addText("TREATMENT ALGORITHM — FIRST LINE", { x: 0.5, y: 0.05, w: 8, h: 0.62,
    fontSize: 18, bold: true, color: C.white, charSpacing: 2, valign: "middle" });
  s.addText("Slide 4 of 5", { x: 11.5, y: 0.05, w: 1.6, h: 0.62,
    fontSize: 9, color: C.muted, align: "right", valign: "middle" });

  // ── Decision Box: Treat or Watch ─────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x: 4.4, y: 0.85, w: 4.5, h: 0.65,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 2 } });
  s.addText("NEW CLL DIAGNOSIS — Assess Treatment Indication", {
    x: 4.4, y: 0.85, w: 4.5, h: 0.65, fontSize: 9, bold: true, color: C.accent, align: "center", valign: "middle" });

  // Arrow down
  s.addShape(pres.ShapeType.rect, { x: 6.4, y: 1.5, w: 0.5, h: 0.4, fill: { color: C.midBlue } });

  // Two branches
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 1.92, w: 5.5, h: 0.55,
    fill: { color: C.green + "33" }, line: { color: C.green, width: 2 } });
  s.addText("WATCH & WAIT (No treatment needed)", {
    x: 0.45, y: 1.92, w: 5.5, h: 0.55, fontSize: 9.5, bold: true, color: C.green, align: "center", valign: "middle" });

  s.addShape(pres.ShapeType.rect, { x: 7.35, y: 1.92, w: 5.5, h: 0.55,
    fill: { color: C.red + "33" }, line: { color: C.red, width: 2 } });
  s.addText("TREAT — Meets IWCLL Criteria", {
    x: 7.35, y: 1.92, w: 5.5, h: 0.55, fontSize: 9.5, bold: true, color: C.red, align: "center", valign: "middle" });

  // Watch & Wait indications
  s.addText("Indications for W&W:", { x: 0.5, y: 2.55, w: 5.3, h: 0.3, fontSize: 8.5, bold: true, color: C.muted });
  const wwItems = ["Early Rai 0-II / Binet A-B (asymptomatic)", "No anemia or thrombocytopenia", "Lymphocyte doubling time > 12 months", "No B symptoms (fever, night sweats, wt loss)"];
  wwItems.forEach((t, i) => {
    s.addShape(pres.ShapeType.ellipse, { x: 0.52, y: 2.9 + i * 0.4 + 0.07, w: 0.17, h: 0.17, fill: { color: C.green } });
    s.addText(t, { x: 0.76, y: 2.88 + i * 0.4, w: 5.0, h: 0.36, fontSize: 8.5, color: C.light });
  });
  s.addText("Monitor: CBC every 3-6 months", { x: 0.5, y: 4.5, w: 5.3, h: 0.35,
    fontSize: 8.5, color: C.gold, italic: true });

  // Treatment criteria
  s.addText("IWCLL Treatment Triggers:", { x: 7.4, y: 2.55, w: 5.3, h: 0.3, fontSize: 8.5, bold: true, color: C.muted });
  const txItems = ["B symptoms (fever/night sweats/wt loss >10%)", "Progressive marrow failure (↑ anemia/thrombocytopenia)", "Massive/progressive splenomegaly or lymphadenopathy", "Lymphocyte doubling time < 6 months", "AIHA/ITP not responsive to corticosteroids"];
  txItems.forEach((t, i) => {
    s.addShape(pres.ShapeType.rect, { x: 7.42, y: 2.9 + i * 0.38 + 0.07, w: 0.17, h: 0.17, fill: { color: C.red } });
    s.addText(t, { x: 7.66, y: 2.88 + i * 0.38, w: 5.0, h: 0.36, fontSize: 8.5, color: C.light });
  });

  // ── Treatment Options ─────────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x: 6.8, y: 4.55, w: 6.1, h: 0.38,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 1 } });
  s.addText("PREFERRED FIRST-LINE REGIMENS (NCCN v2.2026)", { x: 6.8, y: 4.55, w: 6.1, h: 0.38,
    fontSize: 9, bold: true, color: C.accent, align: "center" });

  const txOptions = [
    { drug: "Zanubrutinib", dose: "160 mg BID, continuous", cat: "BTK inhibitor", pref: "PREFERRED", color: C.green },
    { drug: "Acalabrutinib", dose: "100 mg BID ± obinutuzumab, continuous", cat: "BTK inhibitor", pref: "PREFERRED", color: C.green },
    { drug: "Ibrutinib", dose: "420 mg OD, continuous", cat: "BTK inhibitor", pref: "Acceptable", color: C.gold },
    { drug: "Venetoclax + Obinutuzumab", dose: "Ramp to 400 mg OD × 1 yr fixed", cat: "BCL2 + Anti-CD20", pref: "PREFERRED", color: C.green },
  ];

  txOptions.forEach((r, i) => {
    const rx = 6.85 + (i % 2) * 3.05;
    const ry = 5.02 + Math.floor(i / 2) * 0.92;
    s.addShape(pres.ShapeType.rect, { x: rx, y: ry, w: 2.95, h: 0.82,
      fill: { color: C.panel }, line: { color: r.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x: rx, y: ry, w: 2.95, h: 0.26, fill: { color: r.color + "44" } });
    s.addText(r.drug, { x: rx + 0.05, y: ry, w: 2.2, h: 0.26, fontSize: 9, bold: true, color: r.color, valign: "middle", margin: 2 });
    s.addShape(pres.ShapeType.rect, { x: rx + 2.25, y: ry + 0.03, w: 0.65, h: 0.21,
      fill: { color: r.color + "88" } });
    s.addText(r.pref, { x: rx + 2.25, y: ry + 0.03, w: 0.65, h: 0.21,
      fontSize: 6, bold: true, color: C.white, align: "center", valign: "middle" });
    s.addText(r.cat, { x: rx + 0.05, y: ry + 0.28, w: 2.85, h: 0.24, fontSize: 7.5, color: C.muted });
    s.addText(r.dose, { x: rx + 0.05, y: ry + 0.52, w: 2.85, h: 0.28, fontSize: 7.5, color: C.light });
  });

  // Note
  s.addText("Note: For del(17p)/TP53-mutated CLL → BTK inhibitors are mandatory (chemo not effective). FCR still considered in fit young patients with mutated IGHV, favorable cytogenetics.", {
    x: 0.45, y: 7.1, w: 12.7, h: 0.34, fontSize: 7.5, color: C.gold, italic: true });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — Drug Details & Monitoring
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 7.5, fill: { color: C.orange } });

  // Title bar
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0, w: 12.95, h: 0.72, fill: { color: C.panel } });
  s.addText("DRUG DETAILS, MONITORING & RELAPSED CLL", { x: 0.5, y: 0.05, w: 9, h: 0.62,
    fontSize: 18, bold: true, color: C.white, charSpacing: 2, valign: "middle" });
  s.addText("Slide 5 of 5", { x: 11.5, y: 0.05, w: 1.6, h: 0.62,
    fontSize: 9, color: C.muted, align: "right", valign: "middle" });

  // ── Drug Table ─────────────────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 0.85, w: 12.45, h: 0.38,
    fill: { color: C.midBlue } });
  const drugHdrs = ["Drug", "Mechanism", "Dose", "Key Adverse Effects", "Monitoring"];
  const drugHdrW = [1.8, 1.9, 2.2, 3.5, 3.0];
  let hx = 0.45;
  drugHdrs.forEach((h, i) => {
    s.addText(h, { x: hx + 0.04, y: 0.85, w: drugHdrW[i], h: 0.38,
      fontSize: 9, bold: true, color: C.white, valign: "middle" });
    hx += drugHdrW[i];
  });

  const drugs = [
    ["Ibrutinib", "BTK inhibitor (1st gen)", "420 mg OD oral", "AF (10%), bleeding, HTN, rash, arthralgias", "ECG baseline, BP, CBC monthly", C.gold],
    ["Acalabrutinib", "BTK inhibitor (2nd gen)", "100 mg BID oral", "Headache, cough, less AF risk vs ibrutinib", "CBC, LFT q3 months", C.green],
    ["Zanubrutinib", "BTK inhibitor (3rd gen)", "160 mg BID oral", "Least cardiac risk; neutropenia, rash", "CBC, LFT q3 months", C.green],
    ["Venetoclax", "BCL2 inhibitor", "Ramp-up → 400 mg OD", "Tumor lysis syndrome (TLS!), neutropenia, N/V/D", "TLS labs D1, D8, D15; CBC weekly", C.red],
    ["Obinutuzumab", "Anti-CD20 monoclonal Ab", "IV per protocol cycles", "Infusion reactions, neutropenia, HBV reactivation", "HBV serology before; CBC each cycle", C.orange],
    ["Rituximab", "Anti-CD20 monoclonal Ab", "375-500 mg/m² IV", "Infusion reactions, PML risk", "HBV, CBC, LFT", C.orange],
    ["Bendamustine", "Alkylating agent", "70-90 mg/m² IV D1+2", "Myelosuppression, infections, nausea", "CBC day 21-28, LFT", C.muted],
    ["Fludarabine", "Purine analogue", "25 mg/m² IV D1-3", "Prolonged myelosuppression, autoimmune AIHA", "CBC; avoid if del(17p)", C.muted],
  ];

  drugs.forEach((d, i) => {
    const ry = 1.3 + i * 0.52;
    const bg = i % 2 === 0 ? C.panel : C.deepBlue;
    s.addShape(pres.ShapeType.rect, { x: 0.45, y: ry, w: 12.45, h: 0.5, fill: { color: bg } });
    let dx = 0.45;
    const vals = [d[0], d[1], d[2], d[3], d[4]];
    vals.forEach((v, j) => {
      const isFirst = j === 0;
      s.addText(v, { x: dx + 0.04, y: ry, w: drugHdrW[j] - 0.08, h: 0.5,
        fontSize: isFirst ? 9 : 8, bold: isFirst, color: isFirst ? d[5] : C.light, valign: "middle", margin: 2 });
      dx += drugHdrW[j];
    });
  });

  // ── Prophylaxis box ─────────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 5.55, w: 5.9, h: 0.35,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 1 } });
  s.addText("SUPPORTIVE PROPHYLAXIS", { x: 0.45, y: 5.55, w: 5.9, h: 0.35,
    fontSize: 9, bold: true, color: C.accent, align: "center" });
  const prophylaxis = [
    "Acyclovir 400 mg BID — Viral (HSV/VZV) prophylaxis during treatment",
    "TMP-SMX — PCP prophylaxis with venetoclax or steroid combos",
    "Posaconazole/Fluconazole — Antifungal prophylaxis (ECIL 2025)",
    "IVIG — Recurrent infections with hypogammaglobulinemia",
    "Prednisolone — AIHA or ITP complicating CLL",
  ];
  prophylaxis.forEach((p, i) => {
    s.addText("• " + p, { x: 0.55, y: 5.96 + i * 0.3, w: 5.7, h: 0.28,
      fontSize: 7.8, color: C.light });
  });

  // ── Relapsed CLL ───────────────────────────────────────────────────────────
  s.addShape(pres.ShapeType.rect, { x: 6.55, y: 5.55, w: 6.35, h: 0.35,
    fill: { color: C.red + "44" }, line: { color: C.red, width: 1 } });
  s.addText("RELAPSED / REFRACTORY CLL", { x: 6.55, y: 5.55, w: 6.35, h: 0.35,
    fontSize: 9, bold: true, color: C.red, align: "center" });
  const relapsedTx = [
    "Switch BTK inhibitor class (e.g. ibrutinib → acalabrutinib/zanubrutinib)",
    "Venetoclax + rituximab — If not previously used",
    "Pirtobrutinib (non-covalent BTK inhibitor) — After covalent BTK failure",
    "Allo-SCT — High-risk young patients, multiply relapsed",
    "CAR-T cell therapy — Investigational in R/R CLL with del(17p)",
  ];
  relapsedTx.forEach((p, i) => {
    s.addText("• " + p, { x: 6.65, y: 5.96 + i * 0.3, w: 6.1, h: 0.28,
      fontSize: 7.8, color: C.light });
  });

  // Final footer
  s.addText("Sources: Harrison's Principles of Internal Medicine 22E (2025) | Goldman-Cecil Medicine | NCCN CLL/SLL Guidelines v2.2026 | GELLC Spanish Guidelines 2025", {
    x: 0.45, y: 7.2, w: 12.7, h: 0.25, fontSize: 6.5, color: C.muted, italic: true });
}

// ─── Write file ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/cll-reference/CLL_Clinical_Reference_Card.pptx" })
  .then(() => console.log("SUCCESS: CLL_Clinical_Reference_Card.pptx written"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

Running Command

cd /home/daytona/workspace/cll-reference && node cll_card.js

Running Command

cd /home/daytona/workspace/cll-reference && node -e " // Fix: replace all 8-char hex colors (with alpha) with proper 6-char hex via transparency object const fs = require('fs'); let code = fs.readFileSync('cll_card.js', 'utf8'); // Replace color + '33' style with fill: { color: ..., transparency: 80 } // We need to do this in-place in the shapes - simpler: just replace the hex patterns // Pattern: C.xxx + '33' => use lighter solid color instead // Map our alpha shortcuts to solid approximations: const replacements = [ [/\{ color: r\[3\] \+ '33' \}/g, \"{ color: 'FFFFFF', transparency: 85 }\"], [/\{ color: r\[3\] \+ '44' \}/g, \"{ color: 'FFFFFF', transparency: 80 }\"], [/\{ color: r\[3\] \+ '55' \}/g, \"{ color: 'FFFFFF', transparency: 75 }\"], [/\{ color: r\[3\] \+ '88' \}/g, \"{ color: 'FFFFFF', transparency: 60 }\"], [/\{ color: C\.green \+ '33' \}/g, \"{ color: '1A5C34', transparency: 0 }\"], [/\{ color: C\.green \+ '44' \}/g, \"{ color: '1E6B3E' }\"], [/\{ color: C\.green \+ '55' \}/g, \"{ color: '1E7A45' }\"], [/\{ color: C\.green \+ '88' \}/g, \"{ color: '27AE60' }\"], [/\{ color: C\.red \+ '33' \}/g, \"{ color: '5C1A1A' }\"], [/\{ color: C\.red \+ '44' \}/g, \"{ color: '6B1E1E' }\"], [/\{ color: C\.red \+ '55' \}/g, \"{ color: '7A2020' }\"], [/\{ color: C\.red \+ '88' \}/g, \"{ color: 'A93226' }\"], [/\{ color: C\.gold \+ '33' \}/g, \"{ color: '4A3A10' }\"], [/\{ color: C\.gold \+ '44' \}/g, \"{ color: '5A4612' }\"], [/\{ color: C\.gold \+ '55' \}/g, \"{ color: '6B5215' }\"], [/\{ color: C\.gold \+ '88' \}/g, \"{ color: 'B8892E' }\"], [/\{ color: C\.orange \+ '33' \}/g, \"{ color: '4A2D08' }\"], [/\{ color: C\.orange \+ '44' \}/g, \"{ color: '5A3609' }\"], [/\{ color: C\.orange \+ '88' \}/g, \"{ color: 'B5770E' }\"], [/\{ color: C\.accent \+ '33' \}/g, \"{ color: '003B4D' }\"], [/\{ color: C\.midBlue \+ '33' \}/g, \"{ color: '0A2140' }\"], [/\{ color: r\[4\] \+ '33' \}/g, \"{ color: '0E2030' }\"], [/\{ color: r\[4\] \+ '44' \}/g, \"{ color: '0E2535' }\"], [/\{ color: r\[4\] \+ '88' \}/g, \"{ color: '1E4A6A' }\"], [/\{ color: m\.color \+ '33' \}/g, \"{ color: '0E2030' }\"], [/\{ color: r\.color \+ '33' \}/g, \"{ color: '0E2030' }\"], [/\{ color: r\.color \+ '44' \}/g, \"{ color: '0E2535' }\"], [/\{ color: r\.color \+ '88' \}/g, \"{ color: '1E4A6A' }\"], [/\{ color: C\.red \+ \"44\" \}/g, \"{ color: '6B1E1E' }\"], ]; replacements.forEach(([pat, repl]) => { code = code.replace(pat, repl); }); fs.writeFileSync('cll_card_fixed.js', code); console.log('Done writing fixed version'); "

Running Command

cd /home/daytona/workspace/cll-reference && node cll_card_fixed.js 2>&1 | head -30

Writing File

~/cll-reference/cll_final.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_WIDE"; // 13.3" x 7.5"
pres.title = "CLL Clinical Reference Card";
pres.author = "Orris Medical";

// ─── Color Palette (all 6-digit hex only) ───────────────────────────────────
const C = {
  navy:    "0A1628",
  deepBlue:"0D2137",
  blue:    "1A3A5C",
  midBlue: "1E5799",
  accent:  "00C2FF",
  gold:    "F4B942",
  green:   "2ECC71",
  red:     "E74C3C",
  orange:  "F39C12",
  white:   "FFFFFF",
  light:   "E8F4FF",
  muted:   "8BA8C4",
  panel:   "112240",
  panel2:  "0E1F38",
  panel3:  "163352",
  success: "27AE60",
  warn:    "E67E22",
  // Pre-mixed "tinted" solids for semi-transparent effects
  greenDark:  "1A5C34",
  greenMid:   "217A46",
  greenLight: "27AE60",
  redDark:    "5C1A1A",
  redMid:     "7A2020",
  redLight:   "A93226",
  goldDark:   "4A3A10",
  goldMid:    "6B5215",
  goldLight:  "B8892E",
  orangeDark: "4A2D08",
  orangeMid:  "5A3609",
  blueDark:   "0A2140",
  blueAccent: "003B4D",
};

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 1 — Title / Cover
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();

  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 7.5, fill: { color: C.accent } });
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0, w: 12.95, h: 0.06, fill: { color: C.accent } });
  s.addShape(pres.ShapeType.rect, { x: 8.5, y: 0.5, w: 4.5, h: 6.5,
    fill: { color: C.panel }, line: { color: C.midBlue, width: 1 } });

  // Blood cell decorative circles
  s.addShape(pres.ShapeType.ellipse, { x: 9.2, y: 1.0, w: 3.1, h: 3.1,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 2 } });
  s.addShape(pres.ShapeType.ellipse, { x: 9.6, y: 1.4, w: 2.3, h: 2.3,
    fill: { color: C.deepBlue }, line: { color: C.midBlue, width: 1 } });
  s.addText("🩸", { x: 9.9, y: 1.7, w: 1.7, h: 1.7, fontSize: 54, align: "center", valign: "middle" });

  s.addText("HAEMATOLOGY", { x: 8.8, y: 4.4, w: 4.2, h: 0.45,
    fontSize: 11, bold: true, color: C.accent, charSpacing: 4, align: "center" });
  s.addText("QUICK REFERENCE", { x: 8.8, y: 4.85, w: 4.2, h: 0.38,
    fontSize: 9, color: C.muted, charSpacing: 3, align: "center" });
  s.addText("Based on NCCN v2.2026 & Harrison's 22E", { x: 8.5, y: 5.3, w: 4.7, h: 0.35,
    fontSize: 8, color: C.muted, align: "center", italic: true });

  s.addText("CLL", { x: 0.6, y: 1.0, w: 7.6, h: 2.0,
    fontSize: 110, bold: true, color: C.white, fontFace: "Arial Black", align: "left", margin: 0 });
  s.addText("Chronic Lymphocytic Leukemia", { x: 0.65, y: 3.0, w: 7.6, h: 0.7,
    fontSize: 24, color: C.accent, align: "left", charSpacing: 1 });
  s.addText("Clinical Reference Card", { x: 0.65, y: 3.65, w: 7.6, h: 0.55,
    fontSize: 17, color: C.muted, align: "left" });
  s.addShape(pres.ShapeType.rect, { x: 0.65, y: 4.35, w: 6.5, h: 0.04, fill: { color: C.midBlue } });

  const facts = [
    { label: "Most Common", value: "Leukemia in West" },
    { label: "Median Age", value: "70 years" },
    { label: "M:F Ratio", value: "2 : 1" },
    { label: "5-yr Survival", value: "~92%" },
  ];
  facts.forEach((f, i) => {
    const bx = 0.65 + i * 1.9;
    s.addShape(pres.ShapeType.rect, { x: bx, y: 4.55, w: 1.7, h: 0.9,
      fill: { color: C.panel }, line: { color: C.midBlue, width: 1 } });
    s.addText(f.value, { x: bx, y: 4.6, w: 1.7, h: 0.45,
      fontSize: 11, bold: true, color: C.gold, align: "center" });
    s.addText(f.label, { x: bx, y: 5.02, w: 1.7, h: 0.35,
      fontSize: 8, color: C.muted, align: "center" });
  });

  s.addText("Staging  •  Prognostic Markers  •  Treatment Algorithms  •  Monitoring", {
    x: 0.65, y: 6.8, w: 11.0, h: 0.4,
    fontSize: 9, color: C.muted, italic: true
  });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — Diagnosis & Staging
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 7.5, fill: { color: C.accent } });
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0, w: 12.95, h: 0.72, fill: { color: C.panel } });
  s.addText("DIAGNOSIS & STAGING", { x: 0.5, y: 0.05, w: 8, h: 0.62,
    fontSize: 18, bold: true, color: C.white, charSpacing: 2, valign: "middle" });
  s.addText("Slide 2 of 5", { x: 11.5, y: 0.05, w: 1.6, h: 0.62,
    fontSize: 9, color: C.muted, align: "right", valign: "middle" });

  // RAI STAGING header
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 0.9, w: 5.8, h: 0.4,
    fill: { color: C.midBlue }, line: { color: C.accent, width: 1 } });
  s.addText("RAI STAGING SYSTEM", { x: 0.45, y: 0.9, w: 5.8, h: 0.4,
    fontSize: 11, bold: true, color: C.white, align: "center", charSpacing: 2 });

  // stage, description, risk-label, text-color, tint-bg-color
  const raiRows = [
    ["Stage 0", "Lymphocytosis only", "Low Risk", C.green, C.greenDark],
    ["Stage I", "Lymphocytosis + Lymphadenopathy", "Intermediate", C.gold, C.goldDark],
    ["Stage II", "Lymphocytosis + Splenomegaly / Hepatomegaly", "Intermediate", C.gold, C.goldDark],
    ["Stage III", "Lymphocytosis + Anemia (Hgb < 11 g/dL)", "High Risk", C.red, C.redDark],
    ["Stage IV", "Lymphocytosis + Thrombocytopenia (Plt < 100K)", "High Risk", C.red, C.redDark],
  ];
  raiRows.forEach((r, i) => {
    const ry = 1.38 + i * 0.72;
    const bg = i % 2 === 0 ? C.panel : C.deepBlue;
    s.addShape(pres.ShapeType.rect, { x: 0.45, y: ry, w: 5.8, h: 0.66, fill: { color: bg } });
    s.addShape(pres.ShapeType.rect, { x: 0.45, y: ry, w: 0.9, h: 0.66, fill: { color: r[4] } });
    s.addText(r[0], { x: 0.45, y: ry, w: 0.9, h: 0.66, fontSize: 10, bold: true, color: r[3], align: "center", valign: "middle" });
    s.addText(r[1], { x: 1.38, y: ry, w: 3.3, h: 0.66, fontSize: 9, color: C.light, valign: "middle", margin: 4 });
    s.addShape(pres.ShapeType.rect, { x: 4.75, y: ry + 0.1, w: 1.4, h: 0.46,
      fill: { color: r[4] }, line: { color: r[3], width: 1 } });
    s.addText(r[2], { x: 4.75, y: ry + 0.1, w: 1.4, h: 0.46, fontSize: 8, bold: true, color: r[3], align: "center", valign: "middle" });
  });

  // BINET STAGING header
  s.addShape(pres.ShapeType.rect, { x: 6.8, y: 0.9, w: 6.1, h: 0.4,
    fill: { color: C.midBlue }, line: { color: C.gold, width: 1 } });
  s.addText("BINET STAGING SYSTEM", { x: 6.8, y: 0.9, w: 6.1, h: 0.4,
    fontSize: 11, bold: true, color: C.white, align: "center", charSpacing: 2 });

  const binetRows = [
    ["A", "< 3 enlarged lymphoid areas; No anemia / thrombocytopenia", "Median Survival: > 10 yrs", C.green, C.greenDark],
    ["B", ">= 3 enlarged lymphoid areas; No anemia / thrombocytopenia", "Median Survival: 7 yrs", C.gold, C.goldDark],
    ["C", "Anemia (Hgb < 10 g/dL) AND/OR Thrombocytopenia (< 100K)", "Median Survival: 2-4 yrs", C.red, C.redDark],
  ];
  binetRows.forEach((r, i) => {
    const ry = 1.38 + i * 0.78;
    const bg = i % 2 === 0 ? C.panel : C.deepBlue;
    s.addShape(pres.ShapeType.rect, { x: 6.8, y: ry, w: 6.1, h: 0.72, fill: { color: bg } });
    s.addShape(pres.ShapeType.rect, { x: 6.8, y: ry, w: 0.6, h: 0.72, fill: { color: r[4] } });
    s.addText("Stage\n" + r[0], { x: 6.8, y: ry, w: 0.6, h: 0.72, fontSize: 9, bold: true, color: r[3], align: "center", valign: "middle" });
    s.addText(r[1], { x: 7.45, y: ry, w: 3.7, h: 0.72, fontSize: 9, color: C.light, valign: "middle", margin: 4 });
    s.addText(r[2], { x: 11.2, y: ry, w: 1.6, h: 0.72, fontSize: 8, bold: true, color: r[3], align: "center", valign: "middle" });
  });

  // DIAGNOSTIC CRITERIA
  s.addShape(pres.ShapeType.rect, { x: 6.8, y: 3.82, w: 6.1, h: 0.38,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 1 } });
  s.addText("DIAGNOSTIC CRITERIA", { x: 6.8, y: 3.82, w: 6.1, h: 0.38,
    fontSize: 10, bold: true, color: C.accent, align: "center", charSpacing: 1 });

  const diagCrit = [
    "Clonal B-lymphocytes >= 5 x 10^9/L in peripheral blood",
    "Immunophenotype: CD5+, CD19+, CD23+, dim CD20, dim sIg",
    "Smudge (smear) cells on peripheral blood film",
    "< 55% prolymphocytes (>55% = B-PLL, different entity)",
    "Monoclonal B-cell lymphocytosis confirmed by flow cytometry",
  ];
  diagCrit.forEach((d, i) => {
    const dy = 4.27 + i * 0.49;
    s.addShape(pres.ShapeType.ellipse, { x: 6.85, y: dy + 0.12, w: 0.22, h: 0.22, fill: { color: C.accent } });
    s.addText(d, { x: 7.15, y: dy, w: 5.65, h: 0.44, fontSize: 9, color: C.light, valign: "middle" });
  });

  s.addText("* This patient (Chiranjee Lal): Lymphocytosis 80%, Smudge cells present, Thrombocytopenia -> Likely Rai Stage III-IV / Binet C. Awaiting immunophenotyping.", {
    x: 0.45, y: 7.1, w: 12.7, h: 0.34, fontSize: 7.5, color: C.gold, italic: true });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — Prognostic Markers
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 7.5, fill: { color: C.gold } });
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0, w: 12.95, h: 0.72, fill: { color: C.panel } });
  s.addText("PROGNOSTIC MARKERS", { x: 0.5, y: 0.05, w: 8, h: 0.62,
    fontSize: 18, bold: true, color: C.white, charSpacing: 2, valign: "middle" });
  s.addText("Slide 3 of 5", { x: 11.5, y: 0.05, w: 1.6, h: 0.62,
    fontSize: 9, color: C.muted, align: "right", valign: "middle" });

  // FISH CYTOGENETICS
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 0.9, w: 6.0, h: 0.4, fill: { color: C.midBlue } });
  s.addText("FISH CYTOGENETICS (Prognostic Impact)", { x: 0.45, y: 0.9, w: 6.0, h: 0.4,
    fontSize: 10, bold: true, color: C.white, align: "center", charSpacing: 1 });

  // name, freq, risk-label, OS, text-color, bg-tint
  const fishData = [
    ["del(13q) sole", "55%", "Best", "OS > 10 yrs", C.green, C.greenDark],
    ["Normal", "18%", "Good", "OS ~7 yrs", C.green, C.greenDark],
    ["Trisomy 12", "16%", "Intermediate", "OS ~7 yrs", C.gold, C.goldDark],
    ["del(11q)", "18%", "Poor", "OS ~6 yrs", C.orange, C.orangeDark],
    ["del(17p)", "7%", "Very Poor", "OS ~2-3 yrs", C.red, C.redDark],
  ];
  fishData.forEach((r, i) => {
    const ry = 1.37 + i * 0.62;
    const bg = i % 2 === 0 ? C.panel : C.deepBlue;
    s.addShape(pres.ShapeType.rect, { x: 0.45, y: ry, w: 6.0, h: 0.58, fill: { color: bg } });
    s.addText(r[0], { x: 0.5, y: ry, w: 1.8, h: 0.58, fontSize: 9, bold: true, color: r[4], valign: "middle", margin: 3 });
    s.addText("Freq: " + r[1], { x: 2.35, y: ry, w: 0.9, h: 0.58, fontSize: 8, color: C.muted, valign: "middle", align: "center" });
    s.addShape(pres.ShapeType.rect, { x: 3.3, y: ry + 0.1, w: 1.2, h: 0.38, fill: { color: r[5] }, line: { color: r[4], width: 1 } });
    s.addText(r[2], { x: 3.3, y: ry + 0.1, w: 1.2, h: 0.38, fontSize: 8, bold: true, color: r[4], align: "center", valign: "middle" });
    s.addText(r[3], { x: 4.58, y: ry, w: 1.8, h: 0.58, fontSize: 8, color: C.light, valign: "middle" });
  });

  // IGHV MUTATION STATUS
  s.addShape(pres.ShapeType.rect, { x: 6.8, y: 0.9, w: 6.1, h: 0.4, fill: { color: C.midBlue } });
  s.addText("IGHV MUTATION STATUS", { x: 6.8, y: 0.9, w: 6.1, h: 0.4,
    fontSize: 10, bold: true, color: C.white, align: "center", charSpacing: 1 });

  // Mutated panel
  s.addShape(pres.ShapeType.rect, { x: 6.8, y: 1.37, w: 2.9, h: 2.4, fill: { color: C.panel }, line: { color: C.green, width: 2 } });
  s.addShape(pres.ShapeType.rect, { x: 6.8, y: 1.37, w: 2.9, h: 0.38, fill: { color: C.greenDark } });
  s.addText("MUTATED IGHV", { x: 6.8, y: 1.37, w: 2.9, h: 0.38, fontSize: 9, bold: true, color: C.green, align: "center", valign: "middle" });
  [">=2% divergence from germline", "Favorable prognosis", "Slower progression", "Possible cure with FCR*", "ZAP-70 negative", "CD38 negative"].forEach((l, i) => {
    s.addShape(pres.ShapeType.rect, { x: 6.9, y: 1.85 + i * 0.32, w: 0.15, h: 0.15, fill: { color: C.green } });
    s.addText(l, { x: 7.1, y: 1.8 + i * 0.32, w: 2.5, h: 0.3, fontSize: 8.5, color: C.light });
  });

  // Unmutated panel
  s.addShape(pres.ShapeType.rect, { x: 9.8, y: 1.37, w: 3.1, h: 2.4, fill: { color: C.panel }, line: { color: C.red, width: 2 } });
  s.addShape(pres.ShapeType.rect, { x: 9.8, y: 1.37, w: 3.1, h: 0.38, fill: { color: C.redDark } });
  s.addText("UNMUTATED IGHV", { x: 9.8, y: 1.37, w: 3.1, h: 0.38, fontSize: 9, bold: true, color: C.red, align: "center", valign: "middle" });
  ["<2% divergence from germline", "Unfavorable prognosis", "Faster progression", "BTK/BCL2 inhibitors preferred", "ZAP-70 positive", "CD38 positive"].forEach((l, i) => {
    s.addShape(pres.ShapeType.rect, { x: 9.9, y: 1.85 + i * 0.32, w: 0.15, h: 0.15, fill: { color: C.red } });
    s.addText(l, { x: 10.1, y: 1.8 + i * 0.32, w: 2.7, h: 0.3, fontSize: 8.5, color: C.light });
  });

  // OTHER MARKERS
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 4.55, w: 12.45, h: 0.38,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 1 } });
  s.addText("OTHER KEY PROGNOSTIC FACTORS", { x: 0.45, y: 4.55, w: 12.45, h: 0.38,
    fontSize: 10, bold: true, color: C.accent, align: "center", charSpacing: 1 });

  const otherMarkers = [
    { title: "TP53 Mutation", good: "Absent", bad: "Mutated / del(17p)", impact: "Resistance to chemo; mandate BTK/BCL2", color: C.red, tint: C.redDark },
    { title: "beta-2 Microglobulin", good: "< 3.5 mg/L", bad: "> 3.5 mg/L", impact: "Independent poor prognosis marker", color: C.orange, tint: C.orangeDark },
    { title: "Serum Thymidine Kinase", good: "Low", bad: "Elevated", impact: "Rapid disease progression predictor", color: C.gold, tint: C.goldDark },
    { title: "Lymphocyte DT", good: "> 12 months", bad: "< 6 months", impact: "Treatment trigger if < 6 months", color: C.gold, tint: C.goldDark },
  ];
  otherMarkers.forEach((m, i) => {
    const mx = 0.5 + i * 3.1;
    s.addShape(pres.ShapeType.rect, { x: mx, y: 5.0, w: 3.0, h: 2.2, fill: { color: C.panel }, line: { color: m.color, width: 1 } });
    s.addText(m.title, { x: mx, y: 5.02, w: 3.0, h: 0.38, fontSize: 9, bold: true, color: m.color, align: "center" });
    s.addText("Favorable: " + m.good, { x: mx + 0.1, y: 5.46, w: 2.8, h: 0.36, fontSize: 8, color: C.green });
    s.addText("Adverse: " + m.bad, { x: mx + 0.1, y: 5.82, w: 2.8, h: 0.36, fontSize: 8, color: C.red });
    s.addShape(pres.ShapeType.rect, { x: mx + 0.05, y: 6.22, w: 2.9, h: 0.04, fill: { color: C.midBlue } });
    s.addText(m.impact, { x: mx + 0.1, y: 6.28, w: 2.8, h: 0.7, fontSize: 7.5, color: C.muted, italic: true });
  });

  s.addText("CLL-IPI Score integrates: IGHV status + TP53 status + beta-2-microglobulin + clinical stage + age -> Stratifies into Low / Intermediate / High / Very High risk", {
    x: 0.45, y: 7.1, w: 12.7, h: 0.34, fontSize: 7.5, color: C.gold, italic: true });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — Treatment Algorithm
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 7.5, fill: { color: C.green } });
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0, w: 12.95, h: 0.72, fill: { color: C.panel } });
  s.addText("TREATMENT ALGORITHM — FIRST LINE", { x: 0.5, y: 0.05, w: 9, h: 0.62,
    fontSize: 18, bold: true, color: C.white, charSpacing: 2, valign: "middle" });
  s.addText("Slide 4 of 5", { x: 11.5, y: 0.05, w: 1.6, h: 0.62,
    fontSize: 9, color: C.muted, align: "right", valign: "middle" });

  // Decision box
  s.addShape(pres.ShapeType.rect, { x: 4.4, y: 0.85, w: 4.5, h: 0.65,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 2 } });
  s.addText("NEW CLL DIAGNOSIS — Assess Treatment Indication", {
    x: 4.4, y: 0.85, w: 4.5, h: 0.65, fontSize: 9, bold: true, color: C.accent, align: "center", valign: "middle" });

  // Arrow
  s.addShape(pres.ShapeType.rect, { x: 6.4, y: 1.5, w: 0.5, h: 0.4, fill: { color: C.midBlue } });

  // Watch & Wait
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 1.92, w: 5.5, h: 0.55,
    fill: { color: C.greenDark }, line: { color: C.green, width: 2 } });
  s.addText("WATCH & WAIT (No treatment needed)", {
    x: 0.45, y: 1.92, w: 5.5, h: 0.55, fontSize: 9.5, bold: true, color: C.green, align: "center", valign: "middle" });

  // Treat
  s.addShape(pres.ShapeType.rect, { x: 7.35, y: 1.92, w: 5.5, h: 0.55,
    fill: { color: C.redDark }, line: { color: C.red, width: 2 } });
  s.addText("TREAT — Meets IWCLL Criteria", {
    x: 7.35, y: 1.92, w: 5.5, h: 0.55, fontSize: 9.5, bold: true, color: C.red, align: "center", valign: "middle" });

  // W&W items
  s.addText("Indications for W&W:", { x: 0.5, y: 2.55, w: 5.3, h: 0.3, fontSize: 8.5, bold: true, color: C.muted });
  ["Early Rai 0-II / Binet A-B (asymptomatic)", "No anemia or thrombocytopenia", "Lymphocyte doubling time > 12 months", "No B symptoms (fever, night sweats, wt loss)"].forEach((t, i) => {
    s.addShape(pres.ShapeType.ellipse, { x: 0.52, y: 2.9 + i * 0.4 + 0.07, w: 0.17, h: 0.17, fill: { color: C.green } });
    s.addText(t, { x: 0.76, y: 2.88 + i * 0.4, w: 5.0, h: 0.36, fontSize: 8.5, color: C.light });
  });
  s.addText("Monitor: CBC every 3-6 months", { x: 0.5, y: 4.5, w: 5.3, h: 0.35, fontSize: 8.5, color: C.gold, italic: true });

  // IWCLL triggers
  s.addText("IWCLL Treatment Triggers:", { x: 7.4, y: 2.55, w: 5.3, h: 0.3, fontSize: 8.5, bold: true, color: C.muted });
  ["B symptoms (fever / night sweats / wt loss > 10%)", "Progressive marrow failure (worsening anemia/thrombocytopenia)", "Massive/progressive splenomegaly or lymphadenopathy", "Lymphocyte doubling time < 6 months", "AIHA/ITP not responsive to corticosteroids"].forEach((t, i) => {
    s.addShape(pres.ShapeType.rect, { x: 7.42, y: 2.9 + i * 0.38 + 0.07, w: 0.17, h: 0.17, fill: { color: C.red } });
    s.addText(t, { x: 7.66, y: 2.88 + i * 0.38, w: 5.0, h: 0.36, fontSize: 8.5, color: C.light });
  });

  // Preferred regimens header
  s.addShape(pres.ShapeType.rect, { x: 6.8, y: 4.55, w: 6.1, h: 0.38,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 1 } });
  s.addText("PREFERRED FIRST-LINE REGIMENS (NCCN v2.2026)", { x: 6.8, y: 4.55, w: 6.1, h: 0.38,
    fontSize: 9, bold: true, color: C.accent, align: "center" });

  const txOptions = [
    { drug: "Zanubrutinib", dose: "160 mg BID, continuous", cat: "BTK inhibitor (3rd gen)", pref: "PREFERRED", color: C.green, tint: C.greenDark },
    { drug: "Acalabrutinib", dose: "100 mg BID +/- obinutuzumab", cat: "BTK inhibitor (2nd gen)", pref: "PREFERRED", color: C.green, tint: C.greenDark },
    { drug: "Ibrutinib", dose: "420 mg OD, continuous", cat: "BTK inhibitor (1st gen)", pref: "Acceptable", color: C.gold, tint: C.goldDark },
    { drug: "Venetoclax + Obinutuzumab", dose: "Ramp to 400 mg OD x 1 yr", cat: "BCL2 inhibitor + Anti-CD20", pref: "PREFERRED", color: C.green, tint: C.greenDark },
  ];
  txOptions.forEach((r, i) => {
    const rx = 6.85 + (i % 2) * 3.05;
    const ry = 5.02 + Math.floor(i / 2) * 0.92;
    s.addShape(pres.ShapeType.rect, { x: rx, y: ry, w: 2.95, h: 0.82, fill: { color: C.panel }, line: { color: r.color, width: 1.5 } });
    s.addShape(pres.ShapeType.rect, { x: rx, y: ry, w: 2.95, h: 0.26, fill: { color: r.tint } });
    s.addText(r.drug, { x: rx + 0.05, y: ry, w: 2.2, h: 0.26, fontSize: 9, bold: true, color: r.color, valign: "middle", margin: 2 });
    s.addShape(pres.ShapeType.rect, { x: rx + 2.25, y: ry + 0.03, w: 0.65, h: 0.21, fill: { color: r.tint } });
    s.addText(r.pref, { x: rx + 2.25, y: ry + 0.03, w: 0.65, h: 0.21, fontSize: 6, bold: true, color: r.color, align: "center", valign: "middle" });
    s.addText(r.cat, { x: rx + 0.05, y: ry + 0.28, w: 2.85, h: 0.24, fontSize: 7.5, color: C.muted });
    s.addText(r.dose, { x: rx + 0.05, y: ry + 0.52, w: 2.85, h: 0.28, fontSize: 7.5, color: C.light });
  });

  s.addText("Note: For del(17p)/TP53-mutated CLL -> BTK inhibitors are mandatory (chemo ineffective). FCR still considered in fit young patients with mutated IGHV, favorable cytogenetics.", {
    x: 0.45, y: 7.1, w: 12.7, h: 0.34, fontSize: 7.5, color: C.gold, italic: true });
}

// ═══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — Drug Details & Monitoring
// ═══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 13.3, h: 7.5, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.35, h: 7.5, fill: { color: C.orange } });
  s.addShape(pres.ShapeType.rect, { x: 0.35, y: 0, w: 12.95, h: 0.72, fill: { color: C.panel } });
  s.addText("DRUG DETAILS, MONITORING & RELAPSED CLL", { x: 0.5, y: 0.05, w: 9, h: 0.62,
    fontSize: 18, bold: true, color: C.white, charSpacing: 2, valign: "middle" });
  s.addText("Slide 5 of 5", { x: 11.5, y: 0.05, w: 1.6, h: 0.62,
    fontSize: 9, color: C.muted, align: "right", valign: "middle" });

  // Drug Table header
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 0.85, w: 12.45, h: 0.38, fill: { color: C.midBlue } });
  const drugHdrW = [1.8, 1.9, 2.2, 3.5, 3.05];
  ["Drug", "Mechanism", "Dose", "Key Adverse Effects", "Monitoring"].forEach((h, i) => {
    let hx = 0.45 + drugHdrW.slice(0, i).reduce((a, b) => a + b, 0);
    s.addText(h, { x: hx + 0.04, y: 0.85, w: drugHdrW[i], h: 0.38, fontSize: 9, bold: true, color: C.white, valign: "middle" });
  });

  const drugs = [
    ["Ibrutinib",       "BTK inhibitor (1st gen)", "420 mg OD oral",          "AF (10%), bleeding, HTN, rash, arthralgias",          "ECG baseline, BP, CBC monthly",        C.gold],
    ["Acalabrutinib",   "BTK inhibitor (2nd gen)", "100 mg BID oral",         "Headache, cough; less AF risk vs ibrutinib",          "CBC, LFT q3 months",                   C.green],
    ["Zanubrutinib",    "BTK inhibitor (3rd gen)", "160 mg BID oral",         "Least cardiac risk; neutropenia, rash",               "CBC, LFT q3 months",                   C.green],
    ["Venetoclax",      "BCL2 inhibitor",          "Ramp-up -> 400 mg OD",    "Tumor lysis syndrome (TLS!), neutropenia, N/V/D",     "TLS labs D1,D8,D15; CBC weekly",       C.red],
    ["Obinutuzumab",    "Anti-CD20 mAb",           "IV per protocol cycles",  "Infusion reactions, neutropenia, HBV reactivation",   "HBV serology before; CBC each cycle",  C.orange],
    ["Rituximab",       "Anti-CD20 mAb",           "375-500 mg/m2 IV",        "Infusion reactions, PML risk",                        "HBV, CBC, LFT",                        C.orange],
    ["Bendamustine",    "Alkylating agent",         "70-90 mg/m2 IV D1+D2",   "Myelosuppression, infections, nausea",                "CBC day 21-28, LFT",                   C.muted],
    ["Fludarabine",     "Purine analogue",          "25 mg/m2 IV D1-D3",      "Prolonged myelosuppression, autoimmune AIHA",         "CBC; avoid if del(17p)",               C.muted],
  ];

  drugs.forEach((d, i) => {
    const ry = 1.3 + i * 0.52;
    const bg = i % 2 === 0 ? C.panel : C.deepBlue;
    s.addShape(pres.ShapeType.rect, { x: 0.45, y: ry, w: 12.45, h: 0.5, fill: { color: bg } });
    d.slice(0, 5).forEach((v, j) => {
      let dx = 0.45 + drugHdrW.slice(0, j).reduce((a, b) => a + b, 0);
      s.addText(v, { x: dx + 0.04, y: ry, w: drugHdrW[j] - 0.08, h: 0.5,
        fontSize: j === 0 ? 9 : 8, bold: j === 0, color: j === 0 ? d[5] : C.light, valign: "middle", margin: 2 });
    });
  });

  // Prophylaxis
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 5.55, w: 5.9, h: 0.35,
    fill: { color: C.panel3 }, line: { color: C.accent, width: 1 } });
  s.addText("SUPPORTIVE PROPHYLAXIS", { x: 0.45, y: 5.55, w: 5.9, h: 0.35,
    fontSize: 9, bold: true, color: C.accent, align: "center" });
  [
    "Acyclovir 400 mg BID — HSV/VZV prophylaxis during treatment",
    "TMP-SMX — PCP prophylaxis with venetoclax / steroid combos",
    "Posaconazole/Fluconazole — Antifungal prophylaxis (ECIL 2025)",
    "IVIG — Recurrent infections with hypogammaglobulinemia",
    "Prednisolone — For AIHA or ITP complicating CLL",
  ].forEach((p, i) => {
    s.addText("• " + p, { x: 0.55, y: 5.96 + i * 0.3, w: 5.7, h: 0.28, fontSize: 7.8, color: C.light });
  });

  // Relapsed CLL
  s.addShape(pres.ShapeType.rect, { x: 6.55, y: 5.55, w: 6.35, h: 0.35,
    fill: { color: C.redDark }, line: { color: C.red, width: 1 } });
  s.addText("RELAPSED / REFRACTORY CLL", { x: 6.55, y: 5.55, w: 6.35, h: 0.35,
    fontSize: 9, bold: true, color: C.red, align: "center" });
  [
    "Switch BTK inhibitor class (e.g. ibrutinib -> zanubrutinib/acalabrutinib)",
    "Venetoclax + rituximab — If not previously used",
    "Pirtobrutinib (non-covalent BTK inhibitor) — After covalent BTK failure",
    "Allo-SCT — High-risk young patients, multiply relapsed disease",
    "CAR-T cell therapy — Investigational in R/R CLL with del(17p)",
  ].forEach((p, i) => {
    s.addText("• " + p, { x: 6.65, y: 5.96 + i * 0.3, w: 6.1, h: 0.28, fontSize: 7.8, color: C.light });
  });

  s.addText("Sources: Harrison's Principles of Internal Medicine 22E (2025) | Goldman-Cecil Medicine | NCCN CLL/SLL Guidelines v2.2026 | GELLC Spanish Guidelines 2025 (PMID: 39799061)", {
    x: 0.45, y: 7.2, w: 12.7, h: 0.25, fontSize: 6.5, color: C.muted, italic: true });
}

// Write file
pres.writeFile({ fileName: "/home/daytona/workspace/cll-reference/CLL_Clinical_Reference_Card.pptx" })
  .then(() => console.log("SUCCESS"))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

Running Command

cd /home/daytona/workspace/cll-reference && node cll_final.js 2>&1

Your CLL Clinical Reference Card is ready:

CLL Clinical Reference Card

Presentation · PPTX

What's Inside (5 slides, wide-format dark theme)

Slide	Content
1 - Cover	Title slide with key stats (5-yr survival 92%, median age 70, M:F ratio, etc.)
2 - Diagnosis & Staging	Full Rai (Stage 0-IV) + Binet (A/B/C) staging tables with color-coded risk levels; diagnostic criteria checklist; patient-specific annotation
3 - Prognostic Markers	FISH cytogenetics table (del13q to del17p with survival data); IGHV mutated vs unmutated comparison panels; TP53, beta-2 microglobulin, TK1, lymphocyte doubling time cards; CLL-IPI note
4 - Treatment Algorithm	Watch & Wait vs. Treat decision pathway; IWCLL treatment triggers; NCCN v2.2026 preferred regimens (Zanubrutinib, Acalabrutinib, Venetoclax+Obinutuzumab, Ibrutinib) with doses
5 - Drugs & Monitoring	8-drug reference table (mechanism, dose, adverse effects, monitoring); Supportive prophylaxis (Acyclovir, TMP-SMX, antifungals, IVIG); Relapsed/refractory CLL pathway including Pirtobrutinib and CAR-T

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