from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import mm, cm
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.platypus.tableofcontents import TableOfContents
from reportlab.lib.colors import HexColor
import os

OUTPUT = "/tmp/workspace/fmge-surgery/FMGE_Surgery_PYQ_Study_Guide.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE   = HexColor("#1A3A5C")
MID_BLUE    = HexColor("#2E6DA4")
LIGHT_BLUE  = HexColor("#D6E8F7")
ACCENT_TEAL = HexColor("#0D7377")
GREEN_BG    = HexColor("#E8F5E9")
GREEN_DARK  = HexColor("#2E7D32")
ORANGE_BG   = HexColor("#FFF3E0")
ORANGE_DARK = HexColor("#E65100")
YELLOW_BG   = HexColor("#FFFDE7")
RED_BG      = HexColor("#FFEBEE")
RED_DARK    = HexColor("#C62828")
GREY_LIGHT  = HexColor("#F5F5F5")
GREY_MID    = HexColor("#9E9E9E")
WHITE       = colors.white

W, H = A4

# ── Styles ───────────────────────────────────────────────────────────────────
styles = getSampleStyleSheet()

def style(name, parent="Normal", **kw):
    s = ParagraphStyle(name, parent=styles[parent], **kw)
    return s

S_COVER_TITLE = style("CoverTitle", fontSize=28, textColor=WHITE,
                      fontName="Helvetica-Bold", leading=36, alignment=TA_CENTER)
S_COVER_SUB   = style("CoverSub",   fontSize=14, textColor=HexColor("#BBDEFB"),
                      fontName="Helvetica", leading=20, alignment=TA_CENTER)
S_COVER_META  = style("CoverMeta",  fontSize=11, textColor=HexColor("#90CAF9"),
                      fontName="Helvetica", leading=16, alignment=TA_CENTER)

S_CH_TITLE    = style("ChTitle",    fontSize=18, textColor=WHITE,
                      fontName="Helvetica-Bold", leading=24, alignment=TA_LEFT,
                      leftIndent=6)
S_SECTION     = style("Section",    fontSize=13, textColor=DARK_BLUE,
                      fontName="Helvetica-Bold", leading=18, spaceBefore=12,
                      spaceAfter=4)
S_BODY        = style("Body",       fontSize=9.5, textColor=HexColor("#212121"),
                      fontName="Helvetica", leading=14, spaceAfter=4,
                      leftIndent=0, alignment=TA_JUSTIFY)
S_BOLD        = style("Bold",       fontSize=9.5, textColor=HexColor("#212121"),
                      fontName="Helvetica-Bold", leading=14)
S_Q_NUM       = style("QNum",       fontSize=10, textColor=WHITE,
                      fontName="Helvetica-Bold", leading=14, alignment=TA_CENTER)
S_Q_TEXT      = style("QText",      fontSize=10, textColor=DARK_BLUE,
                      fontName="Helvetica-Bold", leading=15, spaceAfter=4,
                      leftIndent=4)
S_OPT         = style("Opt",        fontSize=9.5, textColor=HexColor("#37474F"),
                      fontName="Helvetica", leading=13, leftIndent=12)
S_ANS         = style("Ans",        fontSize=9.5, textColor=GREEN_DARK,
                      fontName="Helvetica-Bold", leading=13, leftIndent=4)
S_EXPL        = style("Expl",       fontSize=9, textColor=HexColor("#424242"),
                      fontName="Helvetica-Oblique", leading=13, leftIndent=4,
                      spaceAfter=2)
S_TAG         = style("Tag",        fontSize=8, textColor=HexColor("#546E7A"),
                      fontName="Helvetica-Oblique", leading=11)
S_TBL_HDR     = style("TblHdr",     fontSize=9, textColor=WHITE,
                      fontName="Helvetica-Bold", leading=12, alignment=TA_CENTER)
S_TBL_CELL    = style("TblCell",    fontSize=8.5, textColor=HexColor("#212121"),
                      fontName="Helvetica", leading=12)
S_FOOTER_NOTE = style("FooterNote", fontSize=8, textColor=GREY_MID,
                      fontName="Helvetica-Oblique", leading=11, alignment=TA_CENTER)
S_TOC_TITLE   = style("TocTitle",   fontSize=16, textColor=DARK_BLUE,
                      fontName="Helvetica-Bold", leading=22, spaceAfter=8,
                      alignment=TA_CENTER)
S_BULLET      = style("Bullet",     fontSize=9.5, textColor=HexColor("#212121"),
                      fontName="Helvetica", leading=14, leftIndent=14,
                      firstLineIndent=-10)
S_KEY_ITEM    = style("KeyItem",    fontSize=9.5, textColor=DARK_BLUE,
                      fontName="Helvetica-Bold", leading=14, leftIndent=4)
S_INTRO_BODY  = style("IntroBody",  fontSize=10, textColor=HexColor("#212121"),
                      fontName="Helvetica", leading=15, spaceAfter=4,
                      alignment=TA_JUSTIFY)

# ── Page template (header + footer) ─────────────────────────────────────────
CHAPTER_TITLE_HOLDER = [""]  # mutable so inner functions can update it

def on_page(canvas, doc):
    canvas.saveState()
    # Header
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(0, H - 28, W, 28, stroke=0, fill=1)
    canvas.setFont("Helvetica-Bold", 9)
    canvas.setFillColor(WHITE)
    canvas.drawString(20, H - 18, "FMGE Surgery PYQ Study Guide  |  2022–2025")
    canvas.drawRightString(W - 20, H - 18, CHAPTER_TITLE_HOLDER[0])
    # Footer
    canvas.setFillColor(GREY_LIGHT)
    canvas.rect(0, 0, W, 20, stroke=0, fill=1)
    canvas.setFont("Helvetica", 8)
    canvas.setFillColor(GREY_MID)
    canvas.drawCentredString(W / 2, 6, f"Page {doc.page}  |  Memory-based questions for practice only")
    canvas.restoreState()

def on_cover_page(canvas, doc):
    canvas.saveState()
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(0, 0, W, H, stroke=0, fill=1)
    # Decorative top stripe
    canvas.setFillColor(MID_BLUE)
    canvas.rect(0, H - 60, W, 60, stroke=0, fill=1)
    canvas.setFillColor(ACCENT_TEAL)
    canvas.rect(0, H - 64, W, 4, stroke=0, fill=1)
    # Bottom stripe
    canvas.setFillColor(MID_BLUE)
    canvas.rect(0, 0, W, 50, stroke=0, fill=1)
    canvas.setFillColor(ACCENT_TEAL)
    canvas.rect(0, 50, W, 4, stroke=0, fill=1)
    canvas.restoreState()

# ── Helper builders ──────────────────────────────────────────────────────────
def chapter_header(title, subtitle=""):
    """Returns a coloured chapter-title block."""
    CHAPTER_TITLE_HOLDER[0] = title
    elems = []
    elems.append(Spacer(1, 2*mm))
    tbl_data = [[Paragraph(title, S_CH_TITLE)]]
    tbl = Table(tbl_data, colWidths=[W - 80])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0, 0), (-1, -1), MID_BLUE),
        ("ROUNDEDCORNERS", [6]),
        ("TOPPADDING",    (0, 0), (-1, -1), 8),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 8),
        ("LEFTPADDING",   (0, 0), (-1, -1), 12),
    ]))
    elems.append(tbl)
    if subtitle:
        elems.append(Spacer(1, 3*mm))
        elems.append(Paragraph(subtitle, S_BODY))
    elems.append(Spacer(1, 4*mm))
    return elems

def question_block(number, year, topic, q_text, options, answer, explanation, tag=""):
    """Returns a self-contained question card."""
    # Number badge + year tag header
    badge_data = [[
        Paragraph(str(number), S_Q_NUM),
        Paragraph(f"<b>{year}</b>  |  {topic}", S_TAG)
    ]]
    badge = Table(badge_data, colWidths=[26, W - 80 - 32])
    badge.setStyle(TableStyle([
        ("BACKGROUND",    (0, 0), (0, 0), MID_BLUE),
        ("BACKGROUND",    (1, 0), (1, 0), LIGHT_BLUE),
        ("VALIGN",        (0, 0), (-1, -1), "MIDDLE"),
        ("TOPPADDING",    (0, 0), (-1, -1), 5),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
        ("LEFTPADDING",   (1, 0), (1, 0), 8),
    ]))

    body_rows = []
    body_rows.append(Paragraph(q_text, S_Q_TEXT))
    body_rows.append(Spacer(1, 2*mm))
    for opt in options:
        body_rows.append(Paragraph(opt, S_OPT))
    body_rows.append(Spacer(1, 2*mm))
    body_rows.append(Paragraph(f"✅  {answer}", S_ANS))
    body_rows.append(Spacer(1, 1*mm))
    body_rows.append(Paragraph(f"<i>{explanation}</i>", S_EXPL))
    if tag:
        body_rows.append(Spacer(1, 1*mm))
        body_rows.append(Paragraph(f"🔖 {tag}", S_TAG))

    body_tbl = Table([[r] for r in body_rows], colWidths=[W - 80])
    body_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0, 0), (-1, -1), GREY_LIGHT),
        ("TOPPADDING",    (0, 0), (-1, -1), 3),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 3),
        ("LEFTPADDING",   (0, 0), (-1, -1), 10),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 10),
    ]))

    block = [badge, body_tbl, Spacer(1, 5*mm)]
    return KeepTogether(block)

def info_box(title, content_paras, bg=LIGHT_BLUE, border=MID_BLUE):
    rows = [[Paragraph(f"<b>{title}</b>", style("IB", fontSize=10,
              textColor=border, fontName="Helvetica-Bold", leading=14))]]
    for p in content_paras:
        rows.append([p])
    tbl = Table(rows, colWidths=[W - 80])
    tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0, 0), (-1, -1), bg),
        ("LINEABOVE",     (0, 0), (-1, 0), 2, border),
        ("TOPPADDING",    (0, 0), (-1, -1), 5),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
        ("LEFTPADDING",   (0, 0), (-1, -1), 10),
        ("RIGHTPADDING",  (0, 0), (-1, -1), 10),
    ]))
    return [tbl, Spacer(1, 4*mm)]

def simple_table(headers, rows, col_widths=None):
    if col_widths is None:
        col_widths = [(W - 80) / len(headers)] * len(headers)
    data = [[Paragraph(h, S_TBL_HDR) for h in headers]]
    for r in rows:
        data.append([Paragraph(str(c), S_TBL_CELL) for c in r])
    tbl = Table(data, colWidths=col_widths)
    style_cmds = [
        ("BACKGROUND",    (0, 0), (-1, 0), DARK_BLUE),
        ("ROWBACKGROUNDS",(0, 1), (-1, -1), [WHITE, GREY_LIGHT]),
        ("GRID",          (0, 0), (-1, -1), 0.4, HexColor("#BDBDBD")),
        ("TOPPADDING",    (0, 0), (-1, -1), 5),
        ("BOTTOMPADDING", (0, 0), (-1, -1), 5),
        ("LEFTPADDING",   (0, 0), (-1, -1), 6),
        ("VALIGN",        (0, 0), (-1, -1), "TOP"),
    ]
    tbl.setStyle(TableStyle(style_cmds))
    return [tbl, Spacer(1, 5*mm)]

# ════════════════════════════════════════════════════════════════════════════
# BUILD DOCUMENT
# ════════════════════════════════════════════════════════════════════════════
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=25*mm, rightMargin=15*mm,
    topMargin=35*mm, bottomMargin=25*mm,
    title="FMGE Surgery PYQ Study Guide 2022–2025",
    author="Orris Medical AI",
    subject="FMGE Surgery Previous Year Questions"
)

story = []

# ── COVER PAGE ───────────────────────────────────────────────────────────────
story.append(Spacer(1, 30*mm))
story.append(Paragraph("FMGE Surgery", S_COVER_TITLE))
story.append(Spacer(1, 4*mm))
story.append(Paragraph("Previous Year Questions Study Guide", S_COVER_SUB))
story.append(Spacer(1, 6*mm))
story.append(HRFlowable(width=120*mm, thickness=1.5, color=ACCENT_TEAL,
                         hAlign="CENTER"))
story.append(Spacer(1, 6*mm))
story.append(Paragraph("Memory-Based PYQs  |  2022 – 2025  |  All Sessions", S_COVER_META))
story.append(Spacer(1, 8*mm))
# Stats strip
stats = [["25 PYQs", "10 Topics", "32–40 Qs in exam", "2022 – 2025"]]
st = Table(stats, colWidths=[38*mm]*4)
st.setStyle(TableStyle([
    ("BACKGROUND",    (0, 0), (-1, -1), ACCENT_TEAL),
    ("TEXTCOLOR",     (0, 0), (-1, -1), WHITE),
    ("FONTNAME",      (0, 0), (-1, -1), "Helvetica-Bold"),
    ("FONTSIZE",      (0, 0), (-1, -1), 10),
    ("ALIGN",         (0, 0), (-1, -1), "CENTER"),
    ("TOPPADDING",    (0, 0), (-1, -1), 8),
    ("BOTTOMPADDING", (0, 0), (-1, -1), 8),
]))
story.append(st)
story.append(Spacer(1, 12*mm))
story.append(Paragraph(
    "Topics covered: Urology · Breast · Thyroid · GI & Hepatobiliary · "
    "Hernia · Trauma · Colorectal · Vascular · Sutures & Principles",
    S_COVER_META))
story.append(Spacer(1, 16*mm))
story.append(Paragraph(
    "Compiled by Orris Medical AI  |  For educational practice only",
    S_COVER_META))
story.append(PageBreak())

# ── HOW TO USE THIS GUIDE ────────────────────────────────────────────────────
CHAPTER_TITLE_HOLDER[0] = "How to Use This Guide"
story += chapter_header("📖  How to Use This Guide")
intro_text = [
    ("What are these questions?",
     "All questions are memory-based recalls from real FMGE exam sessions "
     "(2022–2025). FMGE/NBEMS does not release official papers, so these "
     "recalls are the closest available resource to actual exam content."),
    ("How to practice",
     "Cover the answer and explanation. Read the clinical scenario carefully. "
     "Select your answer, then reveal. Focus on the <b>explanation</b> — "
     "understanding the concept is more valuable than memorising the answer."),
    ("Weightage",
     "Surgery carries approximately <b>32–40 questions (8–10%)</b> of the "
     "300-question FMGE paper, making it the second-highest weighted subject "
     "after Medicine. Urology, Breast, and Thyroid are the heaviest subtopics."),
    ("Repeat topics",
     "Topics marked <b>🔁 Repeating</b> have appeared in 3 or more consecutive "
     "FMGE sessions. Prioritise these for maximum ROI on revision time."),
]
for heading, body in intro_text:
    story.append(Paragraph(f"<b>{heading}</b>", S_SECTION))
    story.append(Paragraph(body, S_INTRO_BODY))
    story.append(Spacer(1, 3*mm))

story.append(Spacer(1, 4*mm))
story += info_box(
    "⚡  Top 12 Highest-Repeat Concepts (appeared in 3+ sessions)",
    [Paragraph(t, S_BULLET) for t in [
        "• Courvoisier's sign — painless jaundice + palpable GB = Ca pancreas",
        "• Stewart-Treves syndrome — lymphangiosarcoma after post-mastectomy lymphedema",
        "• Howship-Romberg sign — obturator hernia (medial thigh pain on hip rotation)",
        "• RLN vs SLN injury after thyroidectomy (hoarseness vs high-pitch voice loss)",
        "• FNAC cannot diagnose follicular thyroid carcinoma — needs lobectomy",
        "• In MEN 2A: operate pheochromocytoma BEFORE thyroidectomy",
        "• BI-RADS 4 = suspicious, biopsy recommended",
        "• Tension pneumothorax = immediate needle decompression — NO X-ray first",
        "• Retrocaval ureter = unilateral hydronephrosis",
        "• AFP is NOT elevated in pure seminoma",
        "• Partial nephrectomy for T1a (≤4 cm) RCC",
        "• Umbilical hernia in children — watchful waiting until age 3–4 years",
    ]],
    bg=YELLOW_BG, border=HexColor("#F9A825")
)
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# CHAPTER 1 — UROLOGY
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Chapter 1: Urology"
story += chapter_header("Chapter 1 — Urology",
    "5–6 questions expected per session | High-yield: RCC staging, testicular tumors, bladder cancer")

story.append(question_block(
    1, "FMGE 2023", "Urology — Renal Cell Carcinoma",
    "A 44-year-old lady presents with a ballotable flank mass. CT imaging shows a 4 cm renal mass. "
    "Urine examination reveals malignant cells. What is the MOST appropriate management?",
    ["A.  Partial nephrectomy",
     "B.  Partial nephrectomy + neoadjuvant chemotherapy",
     "C.  Radical nephrectomy",
     "D.  Radical nephrectomy + postoperative radiotherapy"],
    "A — Partial nephrectomy",
    "For RCC ≤4 cm (T1a), nephron-sparing partial nephrectomy is the standard of care. "
    "Radical nephrectomy is for larger/complex tumors. RCC is radioresistant.",
    "🔁 Repeating | RCC T1a (≤4 cm) → Partial nephrectomy"
))

story.append(question_block(
    2, "FMGE 2023", "Urology — Hydronephrosis",
    "Which of the following causes UNILATERAL hydronephrosis?",
    ["A.  Phimosis",
     "B.  Posterior urethral valves",
     "C.  Urethral strictures",
     "D.  Retrocaval ureter"],
    "D — Retrocaval ureter",
    "Retrocaval (circumcaval) ureter wraps behind the IVC causing right-sided unilateral "
    "hydronephrosis. Options A, B, C are infravesical obstructions causing bilateral hydronephrosis.",
    "🔁 Repeating | Retrocaval ureter = unilateral (right) hydronephrosis"
))

story.append(question_block(
    3, "FMGE June 2024", "Urology — Sex Cord Stromal Tumor",
    "A 40-year-old man presents with gynecomastia. Ultrasound reveals a 1 cm solid intratesticular mass. "
    "Serum testosterone is 600 ng/dL; estradiol is 35 pg/mL. What is the most likely diagnosis?",
    ["A.  Spermatocytic tumor",
     "B.  Sertoli cell tumor",
     "C.  Granulosa cell tumor",
     "D.  Leydig cell tumor"],
    "D — Leydig cell tumor",
    "Leydig (interstitial) cell tumors secrete both androgens and estrogens → gynecomastia. "
    "Small, solid, intratesticular. AFP and hCG NOT elevated. Histological hallmark: Reinke crystals. "
    "Sertoli cell tumors also cause gynecomastia but less commonly tested.",
    "Differentiator: Leydig = Reinke crystals; AFP/hCG negative (not a GCT)"
))

story.append(question_block(
    4, "FMGE 2024–2025", "Urology — Testicular Tumor (Image-based)",
    "A 35-year-old male has a bulky scrotal swelling. Orchidectomy is performed. The gross section "
    "shows a gray-white, homogeneous, lobulated mass WITHOUT hemorrhage or necrosis. "
    "What is the most likely diagnosis?",
    ["A.  Seminoma",
     "B.  Teratoma",
     "C.  Yolk sac tumor",
     "D.  Endodermal sinus tumor"],
    "A — Seminoma",
    "Seminoma: most common testicular GCT in adults (peak 30–40s). Gross: gray-white, homogeneous, "
    "lobulated, NO hemorrhage or necrosis. AFP NOT elevated in pure seminoma. "
    "Radiosensitive. NSGCTs (teratoma, yolk sac) show hemorrhage/necrosis grossly.",
    "🔁 Repeating | Seminoma: AFP negative; gray-white homogeneous gross appearance"
))

story.append(question_block(
    5, "FMGE June 2024", "Urology — Post-mastectomy Complication",
    "A woman had axillary lymph node dissection for breast cancer. Years later she develops "
    "progressive painless arm swelling. The arm now shows purplish skin nodules. "
    "What is the most likely diagnosis?",
    ["A.  Lymphangiosarcoma (Stewart-Treves syndrome)",
     "B.  Thoracic outlet syndrome",
     "C.  Chronic venous insufficiency",
     "D.  Recurrent breast cancer"],
    "A — Lymphangiosarcoma (Stewart-Treves syndrome)",
    "Chronic post-mastectomy lymphedema rarely undergoes malignant transformation to "
    "lymphangiosarcoma — this is Stewart-Treves syndrome. Purplish skin nodules on lymphedematous arm "
    "is a classic FMGE clinical picture.",
    "🔁 Repeating | Stewart-Treves = lymphangiosarcoma complicating chronic lymphedema"
))

story.append(Spacer(1, 4*mm))
story += info_box("📌  Urology Quick-Reference",
    [Paragraph(t, S_BULLET) for t in [
        "• T1a (≤4 cm) RCC → Partial nephrectomy | T1b (4–7 cm) → Partial or radical",
        "• Painless hematuria in adult → bladder TCC until proven otherwise",
        "• Schistosoma haematobium → Squamous cell carcinoma of bladder",
        "• Prostate cancer: peripheral zone; BPH: transitional zone",
        "• Osteoblastic bone mets + elevated ALP → Ca prostate",
        "• VHL gene mutation → Clear cell RCC",
    ]], bg=LIGHT_BLUE, border=MID_BLUE)
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# CHAPTER 2 — BREAST SURGERY
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Chapter 2: Breast Surgery"
story += chapter_header("Chapter 2 — Breast Surgery",
    "5–6 questions expected | High-yield: Paget's, BI-RADS, Cooper's ligaments, MRM, staging")

story.append(question_block(
    6, "FMGE 2024 Jan", "Breast — Investigation Sequence",
    "A 50-year-old woman presents with a breast lump. Mammography shows a spiculated mass with "
    "microcalcifications. FNAC is reported as malignant. What is the MOST appropriate next step "
    "before surgery?",
    ["A.  Lumpectomy alone",
     "B.  Modified radical mastectomy immediately",
     "C.  Core needle biopsy for receptor status before surgery",
     "D.  Radical (Halsted) mastectomy"],
    "C — Core needle biopsy",
    "FNAC provides cytology only; core needle biopsy provides histological type + ER/PR/HER2 receptor "
    "status, which guides surgical plan (BCS vs MRM) and need for neoadjuvant therapy. "
    "Halsted mastectomy is historical and no longer standard.",
    "Triple assessment = Clinical + Imaging + Core biopsy (not just FNAC)"
))

story.append(question_block(
    7, "FMGE 2023–2024", "Breast — Nipple Lesion",
    "A woman presents with a chronic eczematous, weeping lesion around the nipple-areola. "
    "No palpable lump. Biopsy shows large cells with pale, vacuolated cytoplasm in the epidermis. "
    "What is the diagnosis?",
    ["A.  Eczema of the nipple",
     "B.  Bowen's disease",
     "C.  Paget's disease of the breast",
     "D.  Inflammatory carcinoma"],
    "C — Paget's disease of the breast",
    "Paget cells: large malignant cells with pale vacuolated cytoplasm in the nipple epidermis. "
    "Always associated with underlying DCIS or IDC. Key differentiator: eczema improves with topical "
    "steroids; Paget's does not respond.",
    "🔁 Repeating | Paget's = Paget cells in epidermis + underlying DCIS/IDC always"
))

story.append(question_block(
    8, "FMGE July 2025", "Breast — Anatomy / Skin Dimpling",
    "A patient presents with skin dimpling over the breast and nipple retraction. "
    "Which structure is responsible for the skin dimpling?",
    ["A.  Pectoralis major",
     "B.  Cooper's suspensory ligaments",
     "C.  Lactiferous ducts",
     "D.  Superficial fascia"],
    "B — Cooper's suspensory ligaments",
    "Cooper's ligaments are fibrous bands anchoring breast tissue to overlying skin. "
    "When invaded by tumor, they shorten and tether the skin → dimpling. "
    "Central duct involvement → nipple retraction. Peau d'orange = dermal lymphatic obstruction "
    "(seen in inflammatory carcinoma).",
    "🔁 Repeating | Cooper's ligament invasion → skin dimpling"
))

story.append(question_block(
    9, "FMGE July 2025", "Breast — Imaging (BI-RADS)",
    "A 45-year-old woman has a breast mass on mammography. The radiologist assigns BI-RADS category 4. "
    "What does this signify?",
    ["A.  Normal, routine annual screening",
     "B.  Benign finding, 6-month follow-up imaging",
     "C.  Suspicious — tissue biopsy recommended",
     "D.  Highly suggestive of malignancy (>95% chance)"],
    "C — Suspicious; biopsy recommended",
    "BI-RADS: 0=Incomplete | 1=Negative | 2=Benign | 3=Probably benign (6 mo f/u, <2%) | "
    "4=Suspicious (2–95%, biopsy) | 5=Highly suspicious (>95%) | 6=Known malignancy.",
    "🔁 Repeating | BI-RADS 4 = biopsy; BI-RADS 3 = 6-month follow-up"
))

story.append(Spacer(1, 2*mm))
# Breast staging table
story += simple_table(
    ["T Stage", "Definition", "N Stage", "Definition"],
    [
        ["T1", "≤2 cm",             "N0", "No nodes"],
        ["T2", "2–5 cm",            "N1", "Mobile ipsilateral axillary"],
        ["T3", ">5 cm",             "N2", "Fixed axillary"],
        ["T4", "Chest wall/skin",   "N3", "Infraclavicular / supraclavicular / internal mammary"],
    ],
    col_widths=[22*mm, 40*mm, 22*mm, 76*mm]
)
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# CHAPTER 3 — THYROID SURGERY
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Chapter 3: Thyroid Surgery"
story += chapter_header("Chapter 3 — Thyroid Surgery",
    "4–5 questions expected | High-yield: FNAC/Bethesda, MEN 2A sequence, RLN injury")

story.append(question_block(
    10, "FMGE 2024 Jan", "Thyroid — FNAC / Bethesda",
    "A 35-year-old female has a painless thyroid nodule. FNAC report: follicular cells arranged in "
    "microfollicles, no nuclear atypia (Bethesda Category IV — Follicular Neoplasm). "
    "What is the next step?",
    ["A.  Total thyroidectomy immediately",
     "B.  Repeat FNAC in 3 months",
     "C.  Hemithyroidectomy (diagnostic lobectomy)",
     "D.  Radioactive iodine therapy"],
    "C — Hemithyroidectomy (diagnostic lobectomy)",
    "FNAC cannot distinguish follicular adenoma from follicular carcinoma — only histology showing "
    "capsular/vascular invasion can. Therefore diagnostic lobectomy is performed. "
    "If malignancy confirmed → completion total thyroidectomy.",
    "🔁 Repeating | FTC cannot be diagnosed on FNAC alone"
))

story.append(question_block(
    11, "FMGE 2023–2024", "Thyroid — MEN 2A Operative Sequence",
    "A patient with MEN 2A has bilateral pheochromocytomas causing severe hypertension. "
    "They also have medullary thyroid carcinoma. In what order should surgery be performed?",
    ["A.  Thyroidectomy first, then adrenalectomy",
     "B.  Pheochromocytoma (adrenalectomy) FIRST, then thyroidectomy",
     "C.  Both can be done simultaneously",
     "D.  Parathyroidectomy first, then thyroidectomy"],
    "B — Pheochromocytoma first, then thyroidectomy",
    "An untreated pheo can cause a lethal hypertensive crisis under general anesthesia during "
    "thyroid surgery. Rule: always screen for and treat pheo BEFORE any elective surgery in MEN 2A. "
    "MEN 2A = MTC + Pheo + Primary hyperparathyroidism (RET mutation).",
    "🔁 Repeating | MEN 2A: Pheo operated BEFORE thyroidectomy"
))

story.append(question_block(
    12, "FMGE 2024–2025", "Thyroid — Post-op Nerve Injury",
    "A patient develops hoarseness of voice after total thyroidectomy. Which nerve is injured?",
    ["A.  External branch of superior laryngeal nerve (EBSLN)",
     "B.  Recurrent laryngeal nerve — unilateral",
     "C.  Recurrent laryngeal nerve — bilateral",
     "D.  Hypoglossal nerve"],
    "B — Unilateral RLN injury",
    "Unilateral RLN injury = hoarseness (ipsilateral cord in paramedian position). "
    "Bilateral RLN = stridor + respiratory distress → emergency tracheostomy. "
    "EBSLN injury = loss of high-pitched phonation (cricothyroid paralysis) — occurs with "
    "high ligation of the superior thyroid artery.",
    "🔁 Repeating | RLN unilateral = hoarse | RLN bilateral = stridor | EBSLN = high pitch loss"
))

story += info_box("📌  Thyroid Carcinoma Quick-Reference",
    [Paragraph(t, S_BULLET) for t in [
        "• Papillary (most common, >88%): Psammoma bodies, Orphan Annie nuclei, BRAF mutation, lymphatic spread",
        "• Follicular: hematogenous spread (lung/bone), RAS mutation, FNAC cannot diagnose → needs histology",
        "• Medullary: C-cells, calcitonin, amyloid stroma, RET mutation, MEN 2A/2B",
        "• Anaplastic: elderly, worst prognosis (months), rapidly growing",
        "• MEN 2A = MTC + Pheo + Parathyroid | MEN 2B = MTC + Pheo + Mucosal neuromas + Marfanoid habitus",
    ]], bg=ORANGE_BG, border=ORANGE_DARK)
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# CHAPTER 4 — GI & HEPATOBILIARY SURGERY
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Chapter 4: GI & Hepatobiliary"
story += chapter_header("Chapter 4 — GI & Hepatobiliary Surgery",
    "4–5 questions expected | Courvoisier's sign, ZES, PJS, bile leak, esophageal anatomy")

story.append(question_block(
    13, "FMGE 2025 July", "GI — Polyposis Syndrome",
    "A patient has episodic abdominal pain, mucocutaneous hyperpigmentation around the lips, "
    "and recurrent GI bleeding. Colonoscopy shows hamartomatous polyps. What is the diagnosis?",
    ["A.  Familial adenomatous polyposis (FAP)",
     "B.  Peutz-Jeghers syndrome (PJS)",
     "C.  Gardner syndrome",
     "D.  HNPCC / Lynch syndrome"],
    "B — Peutz-Jeghers syndrome",
    "PJS: STK11/LKB1 gene mutation. Triad: hamartomatous polyps (GI) + mucocutaneous melanin "
    "spots (lips, buccal mucosa, perioral) + GI bleeding/intussusception. "
    "FAP = adenomatous polyps, thousands, no pigmentation. Gardner = FAP + desmoids + osteomas.",
    "🔁 Repeating | PJS: STK11 gene, hamartomas + perioral pigmentation"
))

story.append(question_block(
    14, "FMGE 2024–2025", "Hepatobiliary — Obstructive Jaundice",
    "A 55-year-old man has progressive painless jaundice, significant weight loss, and a palpable, "
    "non-tender gallbladder. What is the most likely diagnosis?",
    ["A.  Choledocholithiasis",
     "B.  Carcinoma head of pancreas",
     "C.  Acute cholecystitis",
     "D.  Primary sclerosing cholangitis"],
    "B — Carcinoma head of pancreas (Courvoisier's sign)",
    "Courvoisier's law: Painless jaundice + palpable non-tender GB = NOT due to stones. "
    "Stones → fibrosis → contracted GB (not palpable). Ca head of pancreas → gradual obstruction "
    "→ GB distends. CA 19-9 is the tumor marker. Whipple's = pancreaticoduodenectomy.",
    "🔁 Repeating | Courvoisier = palpable GB + painless jaundice = Ca pancreas"
))

story.append(question_block(
    15, "FMGE July 2025", "GI — Zollinger-Ellison Syndrome",
    "A patient with Zollinger-Ellison syndrome has recurrent peptic ulcers despite PPI therapy. "
    "Where is the MOST common location for gastrinoma?",
    ["A.  Gastric body",
     "B.  Passaro's triangle (gastrinoma triangle)",
     "C.  Pancreatic tail",
     "D.  Sigmoid colon"],
    "B — Passaro's (gastrinoma) triangle",
    "Passaro's triangle = (1) junction of cystic duct & CBD superiorly + (2) junction of 2nd & 3rd "
    "duodenum inferiorly + (3) neck-body junction of pancreas medially. ~90% of gastrinomas arise here. "
    "ZES: hypergastrinemia → multiple/atypical PUs + diarrhea. Associated with MEN 1.",
    "Gastrinoma triangle = most common site of ZES gastrinoma"
))

story.append(question_block(
    16, "FMGE 2023", "GI — Esophageal Anatomy",
    "During esophagoscopy, a fishbone is found impacted at 25 cm from the incisor teeth. "
    "This corresponds to which anatomical constriction of the esophagus?",
    ["A.  Cricopharyngeus (upper esophageal sphincter) — 15 cm",
     "B.  Aortic arch constriction — 22–25 cm",
     "C.  Left main bronchus — 27–28 cm",
     "D.  Lower esophageal sphincter — 38–40 cm"],
    "B — Aortic arch constriction (22–25 cm from incisors)",
    "Esophageal constrictions from incisors: Cricopharyngeus 15 cm | Aortic arch 22–25 cm | "
    "Left main bronchus 27–28 cm | LES/Diaphragm 38–40 cm. "
    "Foreign bodies most commonly lodge at the cricopharyngeus (narrowest point).",
    "Esophageal constriction distances — high FMGE frequency"
))

story.append(question_block(
    17, "FMGE July 2025", "Hepatobiliary — Post-cholecystectomy Bile Leak",
    "A patient develops a bile leak after laparoscopic cholecystectomy. "
    "USG confirms a biloma. What is the sequence of management?",
    ["A.  Immediate re-laparoscopy",
     "B.  CT-guided drainage alone",
     "C.  USG-guided percutaneous drainage of biloma → then ERCP for ductal injury",
     "D.  Conservative management with antibiotics only"],
    "C — USG-guided drainage → ERCP",
    "Post-cholecystectomy bile leak: First drain biloma with USG-guided percutaneous drainage. "
    "Then ERCP with sphincterotomy ± stenting for the bile duct injury. "
    "Strasberg classification grades biliary injuries (A through E).",
    "Strasberg classification used for post-cholecystectomy bile duct injuries"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# CHAPTER 5 — HERNIA
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Chapter 5: Hernia"
story += chapter_header("Chapter 5 — Hernia",
    "4–5 questions expected | Named hernias, Hesselbach's triangle, Howship-Romberg sign")

story.append(question_block(
    18, "FMGE 2022 Dec", "Hernia — Surgical Incision",
    "A 23-year-old male had acute appendicitis 3 days ago and now presents with abdominal pain "
    "and tenderness with a palpable mass in the RIF. Which incision is MOST appropriate?",
    ["A.  McBurney's grid-iron incision",
     "B.  Rutherford-Morrison (muscle-cutting/extended) incision",
     "C.  Lanz transverse incision",
     "D.  Midline laparotomy"],
    "B — Rutherford-Morrison incision",
    "For complicated appendicitis (3 days old, appendix mass / abscess), a Rutherford-Morrison "
    "muscle-cutting extension of the grid-iron provides better access. "
    "McBurney's / Lanz are adequate for simple uncomplicated appendicitis only.",
    "Rutherford-Morrison = extended grid-iron for complicated appendicitis"
))

story.append(question_block(
    19, "FMGE July 2025", "Hernia — Pediatric Umbilical Hernia",
    "A child presents with an umbilical region swelling that reduces spontaneously. "
    "What is the correct management?",
    ["A.  Immediate surgical repair",
     "B.  Watchful waiting — spontaneous closure expected by age 3–4 years",
     "C.  Truss application",
     "D.  Laparoscopic repair at age 1 year"],
    "B — Watchful waiting until age 3–4 years",
    "Umbilical hernias in children have ~90% spontaneous closure rate by age 2–3 years. "
    "Surgery is indicated if: persists beyond age 3–4 years, diameter >2 cm, or complicated. "
    "Paraumbilical hernias in adults do NOT close spontaneously → always repair.",
    "🔁 Repeating | Umbilical hernia in children: wait; in adults: always repair"
))

story.append(question_block(
    20, "FMGE 2024", "Hernia — Obturator Hernia",
    "A 70-year-old thin woman presents with severe medial thigh pain aggravated by hip internal "
    "rotation. A small reducible swelling is found below and lateral to the pubic tubercle. "
    "What is the diagnosis?",
    ["A.  Femoral hernia",
     "B.  Obturator hernia",
     "C.  Inguinal hernia",
     "D.  Spigelian hernia"],
    "B — Obturator hernia",
    "Howship-Romberg sign: medial thigh/knee pain on hip internal rotation + extension = obturator "
    "nerve compression by obturator hernia. 'Little old lady's hernia' — elderly, thin, multiparous. "
    "Passes through obturator foramen. High risk of strangulation.",
    "🔁 Repeating | Howship-Romberg sign = obturator hernia"
))

story += info_box("📌  Named Hernia Quick-Reference",
    [Paragraph(t, S_BULLET) for t in [
        "• Richter's: Only part of bowel wall in sac — can strangulate WITHOUT obstruction",
        "• Littre's: Meckel's diverticulum in sac",
        "• Maydl's (W-hernia): 2 loops in sac; middle loop (abdominal) strangulates",
        "• Sliding: Viscus forms part of sac wall (sigmoid L, cecum R)",
        "• Spigelian: Through linea semilunaris (lateral to rectus)",
        "• Obturator: Howship-Romberg sign; elderly thin women; obturator foramen",
        "• Femoral: Below and lateral to pubic tubercle; highest strangulation risk",
        "• Hesselbach's triangle: Inguinal lig (inf) + inferior epigastric vessels (lat) + rectus (med)",
    ]], bg=GREEN_BG, border=GREEN_DARK)
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# CHAPTER 6 — TRAUMA
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Chapter 6: Trauma (ATLS)"
story += chapter_header("Chapter 6 — Trauma (ATLS)",
    "3–4 questions expected | Tension pneumothorax, blast injury classification, hemorrhagic shock")

story.append(question_block(
    21, "FMGE Jan 2025", "Trauma — Tension Pneumothorax",
    "A road traffic accident victim has: absent breath sounds on right, tracheal deviation to left, "
    "distended neck veins, and BP 80/50 mmHg. What is the IMMEDIATE management?",
    ["A.  Chest X-ray to confirm diagnosis",
     "B.  Needle decompression at 2nd ICS, midclavicular line",
     "C.  Intercostal tube drain at 5th ICS, anterior axillary line",
     "D.  Emergency intubation"],
    "B — Immediate needle decompression (2nd ICS, MCL)",
    "Tension pneumothorax is a CLINICAL diagnosis — do NOT wait for X-ray. "
    "14G cannula at 2nd ICS MCL → releases tension → converts to simple pneumo → "
    "then definitive chest drain (5th ICS, anterior axillary line). "
    "Classic signs: absent BS + tracheal shift away + JVD + hypotension.",
    "🔁 Repeating | Tension pneumo = immediate needle decompression. No X-ray delay!"
))

story.append(question_block(
    22, "FMGE July 2025", "Trauma — Blast Injury Classification",
    "A bomb blast victim sustains a crush injury when thrown by the explosion. "
    "This type of injury is classified as:",
    ["A.  Primary blast injury",
     "B.  Secondary blast injury",
     "C.  Tertiary blast injury",
     "D.  Quaternary blast injury"],
    "C — Tertiary blast injury",
    "Blast injury classification: "
    "Primary = pressure wave (barotrauma — tympanic membrane, lung, bowel) | "
    "Secondary = projectiles/fragments/shrapnel | "
    "Tertiary = victim thrown by blast → crush injuries, fractures | "
    "Quaternary = burns, toxic chemical/biological/radiation exposure.",
    "New addition to FMGE (2025) — remember all 4 blast injury categories"
))

story.append(question_block(
    23, "FMGE Dec 2022", "Trauma — Surgical Site Infection Prevention",
    "What is the IDEAL method of removing hair before surgery to minimize surgical site infection?",
    ["A.  Razor 24 hours before surgery",
     "B.  Hair removal cream on the previous day",
     "C.  Electric hair clippers on the OT table",
     "D.  Razor on the OT table"],
    "C — Electric hair clippers on the OT table",
    "WHO/CDC guidelines: If hair removal is necessary, use electric clippers (not razors) "
    "as close to surgery time as possible (ideally on OT table). "
    "Razors cause microabrasions → 3× higher SSI risk. "
    "Depilatory creams are acceptable alternative but less commonly used.",
    "WHO guideline on surgical site infection prevention"
))

story += info_box("📌  Hemorrhagic Shock Classification (ATLS)",
    [simple_table(
        ["Class", "Blood Loss", "Heart Rate", "BP", "Urine Output"],
        [
            ["I",   "<750 ml (<15%)",       "<100",    "Normal",      ">30 ml/hr"],
            ["II",  "750–1500 ml (15–30%)", "100–120", "Normal",      "20–30 ml/hr"],
            ["III", "1500–2000 ml (30–40%)","120–140", "Decreased",   "5–20 ml/hr"],
            ["IV",  ">2000 ml (>40%)",      ">140",    "Very low",    "<5 ml/hr"],
        ],
        col_widths=[18*mm, 40*mm, 30*mm, 30*mm, 32*mm]
    )[0]],
    bg=RED_BG, border=RED_DARK)
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# CHAPTER 7 — ADDITIONAL HIGH-YIELD PYQs
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Chapter 7: Additional High-Yield PYQs"
story += chapter_header("Chapter 7 — Sutures, Dumping Syndrome & More",
    "Mixed topics from recent sessions including surgical principles, GI complications")

story.append(question_block(
    24, "FMGE July 2025", "Surgical Principles — Suture Types (Image-based)",
    "A suture technique is shown where the needle enters one side, exits, re-enters on the same side "
    "parallel to the first pass, exits the other side, creating a horizontal loop when knotted. "
    "What is this suture?",
    ["A.  Simple interrupted suture",
     "B.  Horizontal mattress suture",
     "C.  Vertical mattress suture",
     "D.  Figure-of-eight suture"],
    "B — Horizontal mattress suture",
    "Simple interrupted: single bite, one knot. "
    "Horizontal mattress: parallel bites on same side → everting wound edges, good hemostasis. "
    "Vertical mattress: one deep + one superficial bite → eliminates dead space. "
    "Figure-of-8: two bites crossed. FMGE 2025 had image-based suture questions — know all types.",
    "FMGE 2025 tested suture technique identification from images"
))

story.append(question_block(
    25, "FMGE 2024–2025", "GI Surgery — Dumping Syndrome",
    "A post-gastrectomy patient develops explosive watery diarrhea, facial flushing, and palpitations "
    "within 30 minutes of eating. What is the most likely diagnosis?",
    ["A.  Afferent loop syndrome",
     "B.  Early dumping syndrome",
     "C.  Late dumping syndrome",
     "D.  Blind loop syndrome"],
    "B — Early dumping syndrome",
    "Early dumping: 15–30 min after meals. Rapid gastric emptying → osmotic fluid shift to small bowel "
    "→ circulating volume falls → vasomotor symptoms (flushing, palpitations, dizziness). "
    "Late dumping: 1–3 hrs post-meal, due to reactive hypoglycemia (insulin surge). "
    "Treatment: small frequent meals, avoid fluids with food, octreotide for refractory cases.",
    "Early dumping = 30 min, vasomotor | Late dumping = 1–3 hr, hypoglycemia"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# QUICK REFERENCE TABLES
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Quick Reference Tables"
story += chapter_header("📊  Quick Reference Tables")

story.append(Paragraph("Named Signs in Surgery", S_SECTION))
story += simple_table(
    ["Sign / Eponym", "Condition"],
    [
        ["Murphy's sign",            "Acute cholecystitis (arrested inspiration on RUQ palpation)"],
        ["Courvoisier's sign",       "Ca head of pancreas (painless jaundice + palpable GB)"],
        ["Howship-Romberg sign",     "Obturator hernia (medial thigh pain on hip rotation)"],
        ["Rovsing's sign",           "Appendicitis (LIF pressure → RIF pain)"],
        ["Psoas sign",               "Retrocecal appendicitis"],
        ["Obturator sign",           "Pelvic appendicitis"],
        ["Charcot's triad",          "Ascending cholangitis (Fever + Jaundice + RUQ pain)"],
        ["Reynolds pentad",          "Charcot's triad + Shock + Confusion (severe cholangitis)"],
        ["Trousseau's sign (malignancy)", "Migratory thrombophlebitis — Ca pancreas"],
        ["Cullen's sign",            "Periumbilical bruising — acute pancreatitis / hemoperitoneum"],
        ["Grey-Turner's sign",       "Flank bruising — retroperitoneal bleed / acute pancreatitis"],
        ["Battle's sign",            "Post-auricular bruising — basal skull fracture"],
        ["Caput medusae",            "Portal hypertension (periumbilical venous dilation)"],
        ["Coffee bean / bent inner tube sign", "Sigmoid volvulus on plain X-ray"],
        ["Rigler's sign (double wall)", "Pneumoperitoneum (free air in peritoneal cavity)"],
        ["Stewart-Treves syndrome",  "Lymphangiosarcoma complicating chronic post-mastectomy lymphedema"],
    ],
    col_widths=[72*mm, 88*mm]
)

story.append(Paragraph("Tumor Markers in Surgery", S_SECTION))
story += simple_table(
    ["Tumor Marker", "Associated Tumor(s)"],
    [
        ["PSA",             "Carcinoma prostate"],
        ["CEA",             "Colorectal cancer (also breast, lung)"],
        ["CA 19-9",         "Carcinoma pancreas (also biliary)"],
        ["CA-125",          "Ovarian cancer"],
        ["AFP",             "Hepatocellular carcinoma; testicular NSGCT (NOT pure seminoma)"],
        ["hCG",             "Choriocarcinoma; gestational trophoblastic disease; seminoma (slight)"],
        ["Calcitonin",      "Medullary thyroid carcinoma (C-cell origin)"],
        ["Urinary 5-HIAA",  "Carcinoid tumor (hepatic mets required for syndrome)"],
        ["VMA / Metanephrines", "Pheochromocytoma"],
        ["Thyroglobulin",   "Post-thyroidectomy surveillance for differentiated thyroid Ca"],
    ],
    col_widths=[50*mm, 110*mm]
)

story.append(Paragraph("Topic-wise FMGE Surgery Frequency (2022–2025)", S_SECTION))
story += simple_table(
    ["Topic", "Frequency", "Key Concepts Tested"],
    [
        ["Urology (RCC, bladder, testis)",    "Very High", "Staging, management, tumor markers, named syndromes"],
        ["Breast (Paget's, BI-RADS, staging)","Very High", "Diagnosis, Cooper's ligaments, staging, surgery"],
        ["Thyroid (FNAC, MEN, RLN)",          "High",      "Bethesda system, MEN 2A operative order"],
        ["GI (Courvoisier, ZES, PJS)",        "High",      "Named syndromes, signs, esophageal anatomy"],
        ["Hernia (types, anatomy)",           "High",      "Named hernias, Howship-Romberg, Hesselbach's"],
        ["Trauma (ATLS, blast)",              "High",      "Tension pneumo management, blast categories"],
        ["Hepatobiliary",                     "Moderate",  "Bile leak, Strasberg, Courvoisier, gallstones"],
        ["Colorectal oncology",               "Moderate",  "FAP vs PJS vs HNPCC, staging, markers"],
        ["Sutures / Wound healing",           "Moderate",  "Suture type identification (image-based)"],
        ["Dumping syndrome",                  "Moderate",  "Early vs late distinction"],
    ],
    col_widths=[48*mm, 26*mm, 86*mm]
)

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════════
# FINAL PAGE — WHERE TO FIND MORE PYQs
# ════════════════════════════════════════════════════════════════════════════
CHAPTER_TITLE_HOLDER[0] = "Resources"
story += chapter_header("📚  Where to Find Full PYQ Papers (Free)")
resources = [
    ("DocTutorials", "https://www.doctutorials.com/fmge/fmge-previous-year-question-papers",
     "July 2025, Jan 2025, 2024, 2023, 2022 papers in PDF — subject-wise breakdown with answers"),
    ("PrepLadder", "https://www.prepladder.com/fmge-study-material/previous-years-question-papers/fmge-previous-year-question-papers",
     "Session-wise papers (June 2024, Jan 2024, 2023) with detailed explanations per question"),
    ("Careers360", "https://medicine.careers360.com/articles/fmge-question-paper",
     "Jan 2026 through 2022 memory-based papers with answer keys and subject-wise analysis"),
    ("Dr. Nishant Bhushan", "https://www.nishantbhushan.in/fmge-1",
     "Free PDFs: 2002–2025 FMGE PYQ papers available for download"),
]
for name, url, desc in resources:
    story.append(Paragraph(f"<b>{name}</b>", S_KEY_ITEM))
    story.append(Paragraph(url, style("URL", fontSize=8.5, textColor=MID_BLUE,
                                       fontName="Helvetica-Oblique", leading=12, leftIndent=12)))
    story.append(Paragraph(desc, S_BODY))
    story.append(Spacer(1, 3*mm))

story.append(Spacer(1, 6*mm))
story += info_box("⚠️  Disclaimer",
    [Paragraph(
        "All questions in this guide are memory-based recalls from FMGE exam sessions "
        "(2022–2025). FMGE/NBEMS does not release official question papers. These questions are "
        "compiled for educational practice only and may not reflect exact wording of original questions. "
        "Always cross-reference with standard surgical textbooks (Bailey &amp; Love, Schwartz's, "
        "Fischer's Mastery) for conceptual accuracy.",
        S_FOOTER_NOTE
    )],
    bg=YELLOW_BG, border=HexColor("#F9A825"))

# ── Build ─────────────────────────────────────────────────────────────────
doc.build(story,
          onFirstPage=on_cover_page,
          onLaterPages=on_page)
print(f"PDF created: {OUTPUT}")

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import mm
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.colors import HexColor

OUTPUT = "/tmp/workspace/fmge-surgery/FMGE_Surgery_PubMed_2024_2026.pdf"
W, H = A4

# ── Colour palette ────────────────────────────────────────────────────────
DARK_NAVY   = HexColor("#0D2137")
MID_BLUE    = HexColor("#1565C0")
LIGHT_BLUE  = HexColor("#BBDEFB")
PALE_BLUE   = HexColor("#E3F2FD")
TEAL        = HexColor("#00695C")
TEAL_LIGHT  = HexColor("#E0F2F1")
RED_DARK    = HexColor("#B71C1C")
RED_LIGHT   = HexColor("#FFEBEE")
ORANGE_DARK = HexColor("#E65100")
ORANGE_LIGHT= HexColor("#FFF3E0")
GREEN_DARK  = HexColor("#2E7D32")
GREEN_LIGHT = HexColor("#E8F5E9")
PURPLE_DARK = HexColor("#4A148C")
PURPLE_LIGHT= HexColor("#F3E5F5")
AMBER_DARK  = HexColor("#F57F17")
AMBER_LIGHT = HexColor("#FFFDE7")
GREY_LIGHT  = HexColor("#F5F5F5")
GREY_MID    = HexColor("#9E9E9E")
WHITE       = colors.white
BLACK       = HexColor("#212121")

# Domain colours: (bg, border, header_bg)
DOMAIN_COLORS = {
    "appendicitis": (HexColor("#FFF8E1"), AMBER_DARK,  HexColor("#FF8F00")),
    "hernia":       (GREEN_LIGHT,         GREEN_DARK,  HexColor("#388E3C")),
    "thyroid":      (TEAL_LIGHT,          TEAL,        HexColor("#00796B")),
    "trauma":       (RED_LIGHT,           RED_DARK,    HexColor("#C62828")),
    "hpb":          (PURPLE_LIGHT,        PURPLE_DARK, HexColor("#6A1B9A")),
    "urology":      (PALE_BLUE,           MID_BLUE,    HexColor("#1976D2")),
}

# ── Styles ────────────────────────────────────────────────────────────────
def S(name, **kw):
    base = kw.pop("parent", "Normal")
    return ParagraphStyle(name, parent=getSampleStyleSheet()[base], **kw)

S_COVER_H1  = S("CH1", fontSize=30, textColor=WHITE, fontName="Helvetica-Bold",
                 leading=38, alignment=TA_CENTER)
S_COVER_H2  = S("CH2", fontSize=14, textColor=HexColor("#BBDEFB"),
                 fontName="Helvetica", leading=20, alignment=TA_CENTER)
S_COVER_SM  = S("CSM", fontSize=10, textColor=HexColor("#90CAF9"),
                 fontName="Helvetica-Oblique", leading=14, alignment=TA_CENTER)
S_CH_TITLE  = S("ChT", fontSize=16, textColor=WHITE, fontName="Helvetica-Bold",
                 leading=22, leftIndent=6)
S_SECTION   = S("Sec", fontSize=11, textColor=DARK_NAVY, fontName="Helvetica-Bold",
                 leading=16, spaceBefore=8, spaceAfter=2)
S_BODY      = S("Bod", fontSize=9,  textColor=BLACK, fontName="Helvetica",
                 leading=13, spaceAfter=3, alignment=TA_JUSTIFY)
S_BODY_BOLD = S("BodB", fontSize=9, textColor=BLACK, fontName="Helvetica-Bold",
                 leading=13)
S_BULLET    = S("Bul", fontSize=9,  textColor=BLACK, fontName="Helvetica",
                 leading=13, leftIndent=14, firstLineIndent=-10, spaceAfter=1)
S_PMID      = S("Pmid", fontSize=8, textColor=HexColor("#546E7A"),
                 fontName="Helvetica-Oblique", leading=11)
S_FINDING   = S("Fnd", fontSize=9,  textColor=GREEN_DARK, fontName="Helvetica-Bold",
                 leading=13, leftIndent=4)
S_FMGE      = S("Fmge", fontSize=9, textColor=MID_BLUE, fontName="Helvetica-Bold",
                 leading=13, leftIndent=4)
S_TAG       = S("Tag", fontSize=8,  textColor=HexColor("#546E7A"),
                 fontName="Helvetica-Oblique", leading=11)
S_TH        = S("Th",  fontSize=8.5, textColor=WHITE, fontName="Helvetica-Bold",
                 leading=12, alignment=TA_CENTER)
S_TC        = S("Tc",  fontSize=8,  textColor=BLACK, fontName="Helvetica",
                 leading=12)
S_TC_SM     = S("TcSm", fontSize=7.5, textColor=BLACK, fontName="Helvetica",
                 leading=11)
S_STAR_LABEL= S("Star", fontSize=9,  textColor=RED_DARK, fontName="Helvetica-Bold",
                 leading=13)
S_FOOTER    = S("Ftr", fontSize=7.5, textColor=GREY_MID, fontName="Helvetica-Oblique",
                 leading=10, alignment=TA_CENTER)

# ── Page callbacks ────────────────────────────────────────────────────────
SECTION_NAME = [""]

def cover_page(canvas, doc):
    canvas.saveState()
    canvas.setFillColor(DARK_NAVY)
    canvas.rect(0, 0, W, H, stroke=0, fill=1)
    canvas.setFillColor(MID_BLUE)
    canvas.rect(0, H - 55, W, 55, stroke=0, fill=1)
    canvas.setFillColor(TEAL)
    canvas.rect(0, H - 59, W, 4, stroke=0, fill=1)
    canvas.setFillColor(MID_BLUE)
    canvas.rect(0, 0, W, 40, stroke=0, fill=1)
    canvas.setFillColor(TEAL)
    canvas.rect(0, 40, W, 4, stroke=0, fill=1)
    canvas.restoreState()

def inner_page(canvas, doc):
    canvas.saveState()
    # Header bar
    canvas.setFillColor(DARK_NAVY)
    canvas.rect(0, H - 26, W, 26, stroke=0, fill=1)
    canvas.setFont("Helvetica-Bold", 8)
    canvas.setFillColor(WHITE)
    canvas.drawString(18, H - 17, "FMGE Surgery  |  PubMed Evidence Digest 2024–2026")
    canvas.setFont("Helvetica", 8)
    canvas.drawRightString(W - 18, H - 17, SECTION_NAME[0])
    # Footer bar
    canvas.setFillColor(GREY_LIGHT)
    canvas.rect(0, 0, W, 18, stroke=0, fill=1)
    canvas.setFont("Helvetica-Oblique", 7.5)
    canvas.setFillColor(GREY_MID)
    canvas.drawCentredString(W / 2, 5,
        f"Page {doc.page}  |  All papers sourced from PubMed  |  For educational use only")
    canvas.restoreState()

# ── Helpers ───────────────────────────────────────────────────────────────
def domain_header(title, subtitle, domain_key):
    SECTION_NAME[0] = title.replace("Domain", "").strip().split("—")[0].strip()
    bg, border, hdr = DOMAIN_COLORS[domain_key]
    row = [[Paragraph(title, S_CH_TITLE)]]
    t = Table(row, colWidths=[W - 72])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), hdr),
        ("TOPPADDING",    (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("LEFTPADDING",   (0,0), (-1,-1), 12),
    ]))
    elems = [Spacer(1, 2*mm), t]
    if subtitle:
        elems += [Spacer(1,2*mm), Paragraph(subtitle, S_BODY)]
    elems.append(Spacer(1, 4*mm))
    return elems

def paper_card(num, landmark, title, authors, journal_year, pmid, doi,
               background, key_findings, fmge_implications,
               domain_key, erratum_note=""):
    bg, border, hdr = DOMAIN_COLORS[domain_key]

    # ── Number badge + title row ─────────────────────────────────────────
    star_txt = "  ⭐ LANDMARK" if landmark else ""
    badge = Table(
        [[Paragraph(f"<b>{num}</b>", S_TH),
          Paragraph(title + star_txt, S("PT", fontSize=9.5, textColor=DARK_NAVY,
                                         fontName="Helvetica-Bold", leading=14))]],
        colWidths=[22, W - 72 - 28]
    )
    badge.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (0,0), border),
        ("BACKGROUND",    (1,0), (1,0), bg),
        ("VALIGN",        (0,0), (-1,-1), "MIDDLE"),
        ("TOPPADDING",    (0,0), (-1,-1), 6),
        ("BOTTOMPADDING", (0,0), (-1,-1), 6),
        ("LEFTPADDING",   (1,0), (1,0), 8),
        ("RIGHTPADDING",  (1,0), (1,0), 6),
    ]))

    # ── Body rows ────────────────────────────────────────────────────────
    rows = []

    # Citation line
    cite_color = HexColor("#37474F")
    rows.append(Paragraph(
        f"<i>{authors}. {journal_year}.</i>  "
        f"PMID: <b>{pmid}</b>  |  DOI: {doi}",
        S("Cite", fontSize=8, textColor=cite_color,
          fontName="Helvetica-Oblique", leading=11, leftIndent=4)))

    if erratum_note:
        rows.append(Paragraph(f"⚠️  {erratum_note}", S("Err", fontSize=8,
            textColor=RED_DARK, fontName="Helvetica-Bold", leading=11, leftIndent=4)))

    rows.append(Spacer(1, 2*mm))

    # Background
    rows.append(Paragraph("<b>Background:</b>  " + background, S_BODY))

    # Key findings header
    rows.append(Spacer(1, 1*mm))
    rows.append(Paragraph("🔬  KEY FINDINGS", S("KFH", fontSize=8.5,
        textColor=GREEN_DARK, fontName="Helvetica-Bold", leading=12)))
    for f in key_findings:
        rows.append(Paragraph("• " + f, S_BULLET))

    # FMGE implication
    rows.append(Spacer(1, 2*mm))
    imp_box_data = [[
        Paragraph("FMGE 2026 IMPLICATION", S("IH", fontSize=8,
            textColor=WHITE, fontName="Helvetica-Bold", leading=11, alignment=TA_CENTER)),
    ]]
    for fi in fmge_implications:
        imp_box_data.append([Paragraph("➤  " + fi, S("IB", fontSize=8.5,
            textColor=MID_BLUE, fontName="Helvetica-Bold", leading=13, leftIndent=6))])
    imp_tbl = Table(imp_box_data, colWidths=[W - 72 - 24])
    imp_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,0), MID_BLUE),
        ("BACKGROUND",    (0,1), (-1,-1), PALE_BLUE),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 8),
        ("LINEABOVE",     (0,0), (-1,0), 1.5, MID_BLUE),
    ]))
    rows.append(imp_tbl)
    rows.append(Spacer(1, 1*mm))

    body_tbl = Table([[r] for r in rows], colWidths=[W - 72])
    body_tbl.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), GREY_LIGHT),
        ("TOPPADDING",    (0,0), (-1,-1), 2),
        ("BOTTOMPADDING", (0,0), (-1,-1), 2),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("RIGHTPADDING",  (0,0), (-1,-1), 10),
    ]))

    return KeepTogether([badge, body_tbl, Spacer(1, 5*mm)])

def info_box(title, items, bg, border):
    rows = [[Paragraph(f"<b>{title}</b>", S("IH2", fontSize=9.5,
              textColor=border, fontName="Helvetica-Bold", leading=14))]]
    for item in items:
        rows.append([item])
    t = Table(rows, colWidths=[W - 72])
    t.setStyle(TableStyle([
        ("BACKGROUND",    (0,0), (-1,-1), bg),
        ("LINEABOVE",     (0,0), (-1,0), 2, border),
        ("TOPPADDING",    (0,0), (-1,-1), 5),
        ("BOTTOMPADDING", (0,0), (-1,-1), 5),
        ("LEFTPADDING",   (0,0), (-1,-1), 10),
        ("RIGHTPADDING",  (0,0), (-1,-1), 10),
    ]))
    return [t, Spacer(1, 5*mm)]

def simple_table(headers, rows_data, col_widths, row_colors=None):
    data = [[Paragraph(h, S_TH) for h in headers]]
    for r in rows_data:
        data.append([Paragraph(str(c), S_TC_SM) for c in r])
    t = Table(data, colWidths=col_widths)
    cmds = [
        ("BACKGROUND",    (0,0), (-1,0), DARK_NAVY),
        ("GRID",          (0,0), (-1,-1), 0.3, HexColor("#BDBDBD")),
        ("TOPPADDING",    (0,0), (-1,-1), 4),
        ("BOTTOMPADDING", (0,0), (-1,-1), 4),
        ("LEFTPADDING",   (0,0), (-1,-1), 5),
        ("VALIGN",        (0,0), (-1,-1), "TOP"),
    ]
    for i in range(1, len(rows_data)+1):
        c = row_colors[i-1] if row_colors else (WHITE if i%2==0 else GREY_LIGHT)
        cmds.append(("BACKGROUND", (0,i), (-1,i), c))
    t.setStyle(TableStyle(cmds))
    return [t, Spacer(1, 5*mm)]

# ════════════════════════════════════════════════════════════════════════
# BUILD STORY
# ════════════════════════════════════════════════════════════════════════
doc = SimpleDocTemplate(
    OUTPUT, pagesize=A4,
    leftMargin=22*mm, rightMargin=13*mm,
    topMargin=33*mm, bottomMargin=23*mm,
    title="FMGE Surgery: PubMed Evidence Digest 2024–2026",
    author="Orris Medical AI",
    subject="Latest Surgery Evidence for FMGE Preparation"
)
story = []

# ── COVER ────────────────────────────────────────────────────────────────
story.append(Spacer(1, 28*mm))
story.append(Paragraph("FMGE Surgery", S_COVER_H1))
story.append(Spacer(1, 3*mm))
story.append(Paragraph("PubMed Evidence Digest", S_COVER_H2))
story.append(Spacer(1, 2*mm))
story.append(Paragraph("2024 – 2026", S_COVER_H2))
story.append(Spacer(1, 6*mm))
story.append(HRFlowable(width=110*mm, thickness=1.5, color=TEAL, hAlign="CENTER"))
story.append(Spacer(1, 6*mm))
story.append(Paragraph(
    "13 High-Impact Papers  |  6 Surgery Domains  |  Systematic Reviews · RCTs · Practice Guidelines",
    S_COVER_SM))
story.append(Spacer(1, 8*mm))

# Stats strip
stats_data = [["13 Papers", "6 Domains", "5 Landmark ⭐", "2024–2026"]]
st = Table(stats_data, colWidths=[38*mm]*4)
st.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), TEAL),
    ("TEXTCOLOR",     (0,0), (-1,-1), WHITE),
    ("FONTNAME",      (0,0), (-1,-1), "Helvetica-Bold"),
    ("FONTSIZE",      (0,0), (-1,-1), 10),
    ("ALIGN",         (0,0), (-1,-1), "CENTER"),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
]))
story.append(st)
story.append(Spacer(1, 8*mm))
story.append(Paragraph(
    "Domains: Appendicitis  ·  Hernia  ·  Thyroid Surgery  ·  Trauma & Shock  ·  "
    "Hepatobiliary  ·  Urology / RCC",
    S_COVER_SM))
story.append(Spacer(1, 10*mm))
story.append(Paragraph(
    "Compiled by Orris Medical AI  |  July 2026  |  All sources verified on PubMed",
    S_COVER_SM))
story.append(PageBreak())

# ── HOW TO USE ────────────────────────────────────────────────────────────
SECTION_NAME[0] = "About This Guide"
story.append(Spacer(1, 2*mm))
hdr_row = [[Paragraph("📋  About This Evidence Digest", S_CH_TITLE)]]
hdr_t = Table(hdr_row, colWidths=[W - 72])
hdr_t.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 12),
]))
story.append(hdr_t)
story.append(Spacer(1, 5*mm))
story.append(Paragraph(
    "This digest compiles 13 high-impact surgery papers published between 2024 and 2026 that "
    "are directly relevant to FMGE examination topics. Each entry includes the paper's background, "
    "key quantitative findings, and a specific FMGE 2026 implication explaining how the evidence "
    "updates or reinforces clinical concepts tested in the exam.",
    S_BODY))
story.append(Spacer(1, 3*mm))

story += info_box(
    "⭐  5 Landmark Papers — Must-Know for FMGE 2026",
    [Paragraph(t, S_BULLET) for t in [
        "• Paper 1  (JAMA 2026)  —  APPAC 10-yr follow-up: Antibiotics are a valid option for uncomplicated appendicitis in adults; ~56% avoid surgery at 10 years",
        "• Paper 2  (Lancet 2025)  —  In children, antibiotics are INFERIOR to appendicectomy (34% vs 7% failure at 1 year)",
        "• Paper 7  (ENT J 2026)  —  Thermal ablation equals surgery for T1aN0M0 papillary thyroid cancer; less permanent RLN injury",
        "• Paper 9  (J Trauma 2026)  —  REBOA shows lower in-hospital mortality vs resuscitative thoracotomy in hemorrhagic shock",
        "• Paper 13  (J Robot Surg 2026)  —  Partial nephrectomy is safe and effective even for pT3a RCC",
    ]],
    bg=AMBER_LIGHT, border=AMBER_DARK
)

story.append(Paragraph("<b>Evidence Tier Key:</b>", S_BODY_BOLD))
story.append(Paragraph("🥇 Systematic Review / Meta-Analysis  |  🥈 Randomised Controlled Trial  |  📋 Practice Guideline", S_BODY))
story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════
# DOMAIN 1 — APPENDICITIS
# ════════════════════════════════════════════════════════════════════════
story += domain_header(
    "Domain 1 — Appendicitis  (FMGE Unit 34)",
    "3 papers • Most significant: antibiotics vs surgery debate resolved by 10-year data",
    "appendicitis"
)

story.append(paper_card(
    num=1, landmark=True,
    title="🥈 Antibiotic Therapy for Uncomplicated Acute Appendicitis: 10-Year Follow-Up of the APPAC RCT",
    authors="Salminen P et al.",
    journal_year="JAMA. 2026 Mar 24",
    pmid="41563747",
    doi="10.1001/jama.2025.25921",
    background=(
        "The APPAC trial originally compared appendectomy vs antibiotics for uncomplicated "
        "acute appendicitis in adults. This 10-year follow-up (530 patients, 6 Finnish hospitals) "
        "is the longest evidence available for antibiotic management."
    ),
    key_findings=[
        "At 10 years, only 37.8% (95% CI 31.6–44.1%) of antibiotic patients had true appendicitis recurrence",
        "Cumulative appendectomy rate at 10 years: 44.3% — meaning 55.7% never needed surgery",
        "Complication rate: appendectomy group 27.4% vs antibiotic group only 8.5% (p<0.001)",
        "Quality of life: no significant difference between antibiotics and appendectomy groups",
        "Antibiotic regimen: IV ertapenem 1g/day × 3 days → oral levofloxacin 500mg + metronidazole 500mg × 7 days",
    ],
    fmge_implications=[
        "Antibiotics are a valid, evidence-based first-line option for uncomplicated appendicitis in ADULTS",
        "\"Antibiotics alone\" is now an acceptable correct answer for uncomplicated appendicitis management",
        "BUT: this only applies to adults with CT-confirmed uncomplicated (non-perforated) appendicitis",
    ],
    domain_key="appendicitis"
))

story.append(paper_card(
    num=2, landmark=True,
    title="🥈 Appendicectomy vs Antibiotics for Acute Uncomplicated Appendicitis in Children: International Multicentre Non-Inferiority RCT",
    authors="St Peter SD, Noel-MacDonnell JR, Hall NJ et al.",
    journal_year="Lancet. 2025 Jan 18",
    pmid="39826968",
    doi="10.1016/S0140-6736(24)02420-6",
    background=(
        "Non-operative management of appendicitis has been gaining traction. This pragmatic "
        "multicentre RCT (11 children's hospitals; Canada, USA, Finland, Sweden, Singapore) "
        "in 936 children aged 5–16 years tested whether antibiotics were non-inferior to "
        "appendicectomy."
    ),
    key_findings=[
        "Treatment failure at 1 year: 34% in antibiotic group vs 7% in surgery group",
        "Difference of 26.7% (90% CI 22.4–30.9%) — exceeds 20% non-inferiority margin → ANTIBIOTICS INFERIOR",
        "4.3× higher risk of mild-to-moderate adverse events in antibiotic group (p<0.0001)",
        "Of children who eventually had appendicectomy from the antibiotic group, 8% had normal pathology",
        "No deaths or serious adverse events in either group",
    ],
    fmge_implications=[
        "CRITICAL CONTRAST: In CHILDREN — antibiotics are INFERIOR to appendicectomy (opposite to adults)",
        "Standard of care in children remains: appendicectomy for uncomplicated appendicitis",
        "FMGE may test this adult vs pediatric distinction — the correct answers differ by age group",
    ],
    domain_key="appendicitis",
    erratum_note="Erratum published — PMID: 39922672"
))

story.append(paper_card(
    num=3, landmark=False,
    title="🥇 Abdominal Drainage to Prevent Intraperitoneal Abscess After Appendectomy for Complicated Appendicitis",
    authors="Tang Y, Liu J, Bai G",
    journal_year="Cochrane Database Syst Rev. 2025 Apr 11",
    pmid="40214287",
    doi="10.1002/14651858.CD010168.pub3",
    background=(
        "After appendectomy for complicated appendicitis (perforated/gangrenous), routine "
        "abdominal drainage is sometimes used to prevent intraperitoneal abscess. This Cochrane "
        "review examined whether drainage actually reduces abscess rates."
    ),
    key_findings=[
        "Evidence remains insufficient to firmly support routine prophylactic drainage after complicated appendicectomy",
        "No definitive benefit of routine drainage in preventing post-operative abscess",
        "Cochrane-level review — highest evidence grade available",
    ],
    fmge_implications=[
        "Routine prophylactic drainage is NOT standard after appendicectomy for complicated appendicitis",
        "Drainage may be used selectively (e.g., large abscess cavity) but not routinely",
    ],
    domain_key="appendicitis"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════
# DOMAIN 2 — HERNIA
# ════════════════════════════════════════════════════════════════════════
story += domain_header(
    "Domain 2 — Hernia  (FMGE Unit 12)",
    "3 papers • Synthetic mesh remains standard; laparoscopic repair safe in all age groups",
    "hernia"
)

story.append(paper_card(
    num=4, landmark=False,
    title="🥇 Synthetic vs Biological Mesh in Laparoscopic Inguinal Hernia Repair: Systematic Review & Meta-Analysis",
    authors="Romano C, Silva H, Gray LA et al.",
    journal_year="BMC Surg. 2025 Oct 8",
    pmid="41063071",
    doi="10.1186/s12893-025-03151-w",
    background=(
        "Biological meshes have been proposed as an alternative to synthetic mesh in "
        "inguinal hernia repair, theoretically offering better tissue integration and "
        "fewer complications. This meta-analysis (1,372 patients; 2015–2025) compared outcomes."
    ),
    key_findings=[
        "Biological mesh (porcine SIS) associated with longer operative time (SMD 0.45, p=0.039)",
        "No significant difference in hernia recurrence (RR 12.73, p=0.15)",
        "No significant difference in complications (RR 3.06, p=0.55) or adverse events",
        "Biological mesh may reduce chronic pain but evidence insufficient",
        "Biological mesh is significantly more expensive with limited long-term data",
    ],
    fmge_implications=[
        "Synthetic mesh remains the gold standard for laparoscopic inguinal hernia repair",
        "Biological mesh shows NO proven superiority in recurrence or complication rates",
        "Classic FMGE teaching: Lichtenstein tension-free repair (open) uses polypropylene mesh; lap uses TEP/TAPP with synthetic mesh",
    ],
    domain_key="hernia",
    erratum_note="Erratum published — PMID: 41413869"
))

story.append(paper_card(
    num=5, landmark=False,
    title="🥇 Open vs Laparoscopic Groin Hernia Repair in Elderly Patients / Octogenarians: Updated Systematic Review & Meta-Analysis",
    authors="Ding Y, Liang B, Zhang R et al.",
    journal_year="Surg Endosc. 2026 Feb",
    pmid="41578020",
    doi="10.1007/s00464-025-11761-z",
    background=(
        "Elderly patients (especially octogenarians >80 years) with inguinal hernia are "
        "often managed conservatively or with open repair due to concerns about laparoscopic "
        "safety. This updated meta-analysis compared both approaches specifically in the elderly."
    ),
    key_findings=[
        "Laparoscopic repair is safe and feasible in elderly patients including octogenarians",
        "Lap repair: reduced post-operative pain, shorter hospital stay, faster return to activity",
        "No significant difference in major perioperative complication rates",
        "Recurrence rates comparable between open and laparoscopic approaches",
    ],
    fmge_implications=[
        "Laparoscopic hernia repair advantages (reduced pain, faster recovery, better cosmesis) apply across all age groups",
        "Age alone is NOT a contraindication to laparoscopic hernia repair",
        "FMGE may present elderly patient scenarios — laparoscopic repair remains appropriate",
    ],
    domain_key="hernia"
))

story.append(paper_card(
    num=6, landmark=False,
    title="🥇 Open vs Laparoscopic Repair in Pediatric Incarcerated Inguinal Hernia: Systematic Review & Meta-Analysis",
    authors="Huang H, Wu H, Hou L et al.",
    journal_year="Hernia. 2026 May 12",
    pmid="42118158",
    doi="10.1007/s10029-026-03287-9",
    background=(
        "Incarcerated inguinal hernias in children require urgent surgical management. "
        "The optimal approach — open vs laparoscopic — has been debated. This meta-analysis "
        "examined outcomes specifically for pediatric incarcerated hernias."
    ),
    key_findings=[
        "Both approaches are safe for pediatric incarcerated inguinal hernia",
        "Laparoscopic repair: better cosmetic results, earlier feeding",
        "Open repair: shorter operative time",
        "No significant difference in recurrence, complication rates, or conversion rates",
    ],
    fmge_implications=[
        "EMERGENCY principle: incarcerated/strangulated hernia requires urgent surgical repair — this does not change",
        "Strangulated hernia with bowel necrosis → resection + repair in same setting",
        "Key FMGE distinction: Richter's hernia can strangulate WITHOUT full bowel obstruction",
    ],
    domain_key="hernia"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════
# DOMAIN 3 — THYROID SURGERY
# ════════════════════════════════════════════════════════════════════════
story += domain_header(
    "Domain 3 — Thyroid Surgery  (FMGE Unit 16)",
    "2 papers • Thermal ablation emerging as equivalent to surgery for low-risk PTC",
    "thyroid"
)

story.append(paper_card(
    num=7, landmark=True,
    title="🥇 Thermal Ablation vs Surgery for Bethesda V & VI Thyroid Cancer (T1aN0M0): Systematic Review & Meta-Analysis",
    authors="Hurtado Amézquita YC, Latorre Nuñez Y, Flórez Romero A et al.",
    journal_year="Ear Nose Throat J. 2026 Mar",
    pmid="37605444",
    doi="10.1177/01455613231189067",
    background=(
        "Differentiated thyroid cancer (mainly papillary) represents 90% of thyroid malignancies. "
        "Standard treatment is surgical. Thermal ablation (microwave, radiofrequency, laser) offers "
        "a minimally invasive alternative for low-risk T1aN0M0 lesions. "
        "This meta-analysis (10 studies, 2,939 patients) compared oncological and safety outcomes."
    ),
    key_findings=[
        "No difference in local recurrence between ablation and surgery: RR 1.17 (95% CI 0.69–1.99)",
        "No difference in cervical lymph node metastasis: RR 0.76 (95% CI 0.43–1.36)",
        "No difference in infection, hematoma, or transient hoarseness rates",
        "SIGNIFICANT: Permanent hoarseness less with thermal ablation vs surgery: RR 0.29 (95% CI 0.11–0.75) — 71% lower risk",
        "Thermal ablation avoids permanent RLN injury more effectively than surgery",
    ],
    fmge_implications=[
        "For T1aN0M0 papillary thyroid carcinoma: thermal ablation = equivalent efficacy to surgery",
        "Thermal ablation carries significantly LESS risk of permanent RLN injury (permanent hoarseness)",
        "This does NOT replace hemithyroidectomy for Bethesda IV (follicular neoplasm) — FNAC still cannot diagnose FTC",
        "CLASSIC FMGE LINK: Permanent hoarseness post-thyroid surgery = RLN injury; high-pitch voice loss = SLN external branch",
    ],
    domain_key="thyroid"
))

story.append(paper_card(
    num=8, landmark=False,
    title="🥇 Active Surveillance of Nodal Metastasis in Differentiated Thyroid Carcinoma: Systematic Review & Meta-Analysis",
    authors="Lavarda Scheinpflug A, Marmitt L, Walter LB et al.",
    journal_year="Endocrine. 2024 Oct",
    pmid="38713330",
    doi="10.1007/s12020-024-03821-6",
    background=(
        "Differentiated thyroid carcinoma (papillary, follicular) often has cervical lymph node "
        "metastases at diagnosis. Immediate lymph node dissection vs active surveillance for "
        "low-volume nodal disease is debated. This review examined outcomes of surveillance."
    ),
    key_findings=[
        "Active surveillance of nodal metastases in low-risk differentiated thyroid cancer is feasible",
        "Low rates of significant nodal progression under surveillance in selected patients",
        "Supports individualized management rather than routine radical neck dissection for small nodal disease",
    ],
    fmge_implications=[
        "Not all cervical LN metastases in differentiated thyroid Ca require immediate surgery",
        "Active surveillance is an evidence-based option for low-volume, low-risk nodal disease",
        "Standard FMGE: Papillary thyroid Ca spreads via LYMPHATICS — regional node dissection for clinically positive nodes",
    ],
    domain_key="thyroid"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════
# DOMAIN 4 — TRAUMA & HEMORRHAGIC SHOCK
# ════════════════════════════════════════════════════════════════════════
story += domain_header(
    "Domain 4 — Trauma & Hemorrhagic Shock  (FMGE Units 1, 19–20)",
    "3 papers • REBOA emerges as superior to resuscitative thoracotomy; restrictive fluids now guideline-endorsed",
    "trauma"
)

story.append(paper_card(
    num=9, landmark=True,
    title="🥇 REBOA vs Resuscitative Thoracotomy for Noncompressible Torso Hemorrhage: Systematic Review & Meta-Analysis",
    authors="Londoño Barrientos M, Amarillo Gutierrez D, López Zapata CA et al.",
    journal_year="J Trauma Acute Care Surg. 2026 Jul 1",
    pmid="41885281",
    doi="10.1097/TA.0000000000004962",
    background=(
        "Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a "
        "catheter-based minimally invasive technique for temporary aortic occlusion in "
        "exsanguinating hemorrhage. This meta-analysis (14 studies, 9,028 patients) compared "
        "REBOA vs resuscitative thoracotomy (RT) with aortic cross-clamping."
    ),
    key_findings=[
        "REBOA: significantly lower in-hospital mortality vs RT — OR 0.17 (95% CI 0.10–0.28), moderate-certainty evidence",
        "Hemorrhagic shock subgroup: OR 0.18 (greater benefit than cardiac arrest subgroup OR 0.32)",
        "Early mortality benefit most pronounced: OR 0.12 (95% CI 0.07–0.23)",
        "REBOA improved neurological outcomes vs RT",
        "REBOA had higher complication rate: OR 7.81 (95% CI 3.88–15.72) and longer aortic occlusion",
        "Conclusion: REBOA preferred strategy when performed by experienced teams in structured trauma systems",
    ],
    fmge_implications=[
        "REBOA = emerging damage control procedure for non-compressible torso hemorrhage — now appearing in FMGE 2026",
        "REBOA is SUPERIOR to emergency resuscitative thoracotomy in hemorrhagic shock (not cardiac arrest)",
        "CLASSIC FMGE: Tension pneumothorax → immediate needle decompression — this principle unchanged",
        "ATLS primary survey (ABCDE) and hemorrhagic shock classification remain high-yield",
    ],
    domain_key="trauma"
))

story.append(paper_card(
    num=10, landmark=True,
    title="📋 ESICM 2025 Clinical Practice Guideline: Fluid Therapy in Critically Ill Adults — Volume of Resuscitation",
    authors="Mekontso Dessap A, AlShamsi F, Belletti A et al.",
    journal_year="Intensive Care Med. 2025 Mar",
    pmid="40163133",
    doi="10.1007/s00134-025-07840-1",
    background=(
        "The European Society of Intensive Care Medicine (ESICM) 2025 guideline provides "
        "evidence-based recommendations on fluid resuscitation volumes for critically ill adults, "
        "using the GRADE framework across multiple shock etiologies."
    ),
    key_findings=[
        "Sepsis/septic shock: administer UP TO 30 ml/kg IV crystalloids in initial phase (very low certainty)",
        "HEMORRHAGIC SHOCK — blunt trauma: RESTRICTIVE fluid strategy recommended (moderate certainty)",
        "HEMORRHAGIC SHOCK — penetrating trauma: RESTRICTIVE fluid strategy recommended (low certainty)",
        "Non-traumatic hemorrhagic shock: guided by hemodynamic and biochemical parameters",
        "Left-sided cardiogenic shock: fluids as primary treatment NOT recommended",
        "Cardiac tamponade: fluids cautiously until definitive treatment (pericardiocentesis/surgery)",
    ],
    fmge_implications=[
        "2025 Guideline confirms: RESTRICTIVE fluids for hemorrhagic trauma shock — avoid crystalloid overload",
        "\"30 ml/kg crystalloids\" is the key figure for SEPTIC shock initial resuscitation",
        "Damage control resuscitation principle: 1:1:1 blood products (pRBC:FFP:platelets) for massive hemorrhage",
        "Permissive hypotension (target SBP 80–90 mmHg) in penetrating hemorrhagic shock until surgical control",
    ],
    domain_key="trauma"
))

story.append(paper_card(
    num=11, landmark=False,
    title="🥇 Adjuvant Therapies for Management of Hemorrhagic Shock: Narrative Review",
    authors="Daniel Y, Dufour-Gaume F, Vergnaud A et al.",
    journal_year="Crit Care. 2025 Mar 29",
    pmid="40158128",
    doi="10.1186/s13054-025-05352-6",
    background=(
        "Beyond fluids and blood products, multiple adjuvant agents (tranexamic acid, "
        "vasopressors, calcium, fibrinogen) are used in hemorrhagic shock. "
        "This review summarises current evidence for adjuvant strategies."
    ),
    key_findings=[
        "Tranexamic acid (TXA): mortality benefit when given within 3 hours of injury (CRASH-2 trial evidence)",
        "Calcium supplementation: important adjunct with massive transfusion (citrate chelation depletes Ca2+)",
        "Fibrinogen concentrate: superior to fresh frozen plasma for fibrinogen replacement",
        "Vasopressors: norepinephrine preferred in distributive component; avoid in pure hemorrhagic shock",
    ],
    fmge_implications=[
        "Tranexamic acid in trauma: give within 3 hours of injury — reduces mortality (high-yield FMGE fact)",
        "1:1:1 ratio of pRBC:FFP:platelets = damage control resuscitation standard",
        "Massive transfusion → hypocalcemia (citrate toxicity) → supplement calcium",
    ],
    domain_key="trauma"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════
# DOMAIN 5 — HEPATOBILIARY
# ════════════════════════════════════════════════════════════════════════
story += domain_header(
    "Domain 5 — Hepatobiliary Surgery  (FMGE Unit 30)",
    "1 paper • Intraoperative cholangiography remains gold standard for bile duct injury prevention",
    "hpb"
)

story.append(paper_card(
    num=12, landmark=False,
    title="🥇 Laparoscopic Ultrasonography vs Intraoperative Cholangiography During Laparoscopic Cholecystectomy: Systematic Review & Meta-Analysis",
    authors="Edebo A, Andersson J, Gustavsson J et al.",
    journal_year="Surg Endosc. 2024 Sep",
    pmid="39020122",
    doi="10.1007/s00464-024-11052-1",
    background=(
        "Bile duct injury (BDI) during laparoscopic cholecystectomy is a rare but serious "
        "complication. Intraoperative cholangiography (IOC) and laparoscopic ultrasonography "
        "(LUS) are used to identify the biliary anatomy and detect CBD stones. "
        "This meta-analysis compared their diagnostic performance."
    ),
    key_findings=[
        "Both LUS and IOC have comparable sensitivity and specificity for detecting CBD stones",
        "IOC remains the gold standard for real-time biliary anatomy visualization",
        "LUS is faster, avoids radiation, no contrast needed — acceptable alternative",
        "Neither technique eliminates bile duct injury risk; critical view of safety (CVS) is essential",
        "Critical View of Safety = complete dissection of hepatocystic triangle with only 2 structures entering gallbladder",
    ],
    fmge_implications=[
        "IOC = gold standard for identifying CBD stones and biliary anatomy during laparoscopic cholecystectomy",
        "Triangle of Calot = cystic duct + common hepatic duct + liver undersurface — cystic artery inside",
        "Bile duct injuries classified by Strasberg system (A–E): FMGE-tested concept",
        "Post-cholecystectomy bile leak management: USG drainage of biloma → ERCP for ductal injury",
    ],
    domain_key="hpb"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════
# DOMAIN 6 — UROLOGY / RCC
# ════════════════════════════════════════════════════════════════════════
story += domain_header(
    "Domain 6 — Urology / Renal Cell Carcinoma  (FMGE Units 21–26)",
    "1 paper • Partial nephrectomy now evidence-supported even for pT3a RCC",
    "urology"
)

story.append(paper_card(
    num=13, landmark=True,
    title="🥇 Partial vs Radical Nephrectomy for pT3a Renal Cell Carcinoma: Systematic Review & Meta-Analysis",
    authors="Gavi F, Rossi F, Fettucciari D et al.",
    journal_year="J Robot Surg. 2026 Apr 21",
    pmid="42010212",
    doi="10.1007/s11701-026-03384-8",
    background=(
        "Standard FMGE teaching: partial nephrectomy (PN) for T1a (≤4 cm) RCC; "
        "radical nephrectomy (RN) for larger/advanced tumors. pT3a RCC (invasion of "
        "perinephric fat, renal vein, or renal sinus) has traditionally been managed with RN. "
        "This meta-analysis (16 studies, 34,304 patients) challenged this paradigm."
    ),
    key_findings=[
        "No significant difference between PN and RN in: estimated blood loss, operative time, hospital stay, major complications (Clavien-Dindo >2)",
        "PN = significantly better renal function preservation vs RN (p<0.01)",
        "PN = higher positive surgical margin rate — but no significant difference in oncological control",
        "PN group had smaller tumors (selection bias acknowledged)",
        "Conclusion: PN is safe and feasible alternative for pT3a RCC — preserves kidney function without compromising oncological outcomes",
    ],
    fmge_implications=[
        "UPDATED TEACHING: Partial nephrectomy is now evidence-supported even for pT3a RCC (beyond the classic T1a rule)",
        "CLASSIC FMGE (still valid): T1a (≤4 cm) → partial nephrectomy is STANDARD of care",
        "Key benefit of PN: better renal function preservation — important in patients with solitary kidney, CKD, or bilateral disease",
        "RCC is RADIORESISTANT — radiotherapy is NOT standard treatment",
    ],
    domain_key="urology"
))

story.append(PageBreak())

# ════════════════════════════════════════════════════════════════════════
# MASTER REFERENCE TABLE
# ════════════════════════════════════════════════════════════════════════
SECTION_NAME[0] = "Master Reference Table"
hdr_row2 = [[Paragraph("📊  Master Reference Table — All 13 Papers", S_CH_TITLE)]]
hdr_t2 = Table(hdr_row2, colWidths=[W - 72])
hdr_t2.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_NAVY),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 12),
]))
story.append(hdr_t2)
story.append(Spacer(1, 4*mm))

row_bg_map = {
    1: AMBER_LIGHT, 2: AMBER_LIGHT, 3: AMBER_LIGHT,
    4: GREEN_LIGHT, 5: GREEN_LIGHT, 6: GREEN_LIGHT,
    7: TEAL_LIGHT,  8: TEAL_LIGHT,
    9: RED_LIGHT,   10: RED_LIGHT, 11: RED_LIGHT,
    12: PURPLE_LIGHT,
    13: PALE_BLUE,
}
star_map = {1:"⭐", 2:"⭐", 7:"⭐", 9:"⭐", 10:"⭐", 13:"⭐"}

master_rows = [
    [1,  "Salminen P et al.",            "JAMA 2026",        "Appendicitis", "APPAC 10-yr: antibiotics valid for adults, 55.7% avoid surgery"],
    [2,  "St Peter SD et al.",           "Lancet 2025",      "Appendicitis", "Antibiotics INFERIOR to appendicectomy in children (34% vs 7% failure)"],
    [3,  "Tang Y et al.",                "Cochrane 2025",    "Appendicitis", "Routine drainage NOT standard after complicated appendicectomy"],
    [4,  "Romano C et al.",              "BMC Surg 2025",    "Hernia",       "Synthetic mesh remains standard; biological mesh no clear benefit"],
    [5,  "Ding Y et al.",                "Surg Endosc 2026", "Hernia",       "Laparoscopic hernia repair safe in elderly/octogenarians"],
    [6,  "Huang H et al.",               "Hernia 2026",      "Hernia",       "Both open/lap safe for pediatric incarcerated hernia; surgery urgent"],
    [7,  "Hurtado Amézquita YC et al.",  "ENT J 2026",       "Thyroid",      "Thermal ablation = surgery for T1aN0M0 PTC; less permanent RLN injury"],
    [8,  "Lavarda Scheinpflug A et al.", "Endocrine 2024",   "Thyroid",      "Active surveillance feasible for low-risk nodal mets in DTC"],
    [9,  "Londoño Barrientos M et al.",  "J Trauma 2026",    "Trauma",       "REBOA superior to resuscitative thoracotomy in hemorrhagic shock (OR 0.17)"],
    [10, "Mekontso Dessap A et al.",     "ICM 2025",         "Trauma/Shock", "ESICM 2025: restrictive fluids for hemorrhagic shock; 30 ml/kg for sepsis"],
    [11, "Daniel Y et al.",              "Crit Care 2025",   "Trauma",       "TXA within 3 hrs, 1:1:1 blood products, calcium supplementation in massive transfusion"],
    [12, "Edebo A et al.",               "Surg Endosc 2024", "HPB",          "IOC = gold standard for biliary anatomy; LUS comparable for CBD stones"],
    [13, "Gavi F et al.",                "J Robot Surg 2026","Urology/RCC",  "Partial nephrectomy safe for pT3a RCC; better renal function vs radical"],
]

tbl_data = [[Paragraph(h, S_TH) for h in ["#", "Authors", "Journal/Year", "Domain", "Key Finding"]]]
for r in master_rows:
    num, auth, jrn, dom, finding = r
    star = star_map.get(num, "")
    tbl_data.append([
        Paragraph(f"<b>{num}</b> {star}", S_TC),
        Paragraph(auth, S_TC_SM),
        Paragraph(jrn, S_TC_SM),
        Paragraph(dom, S_TC_SM),
        Paragraph(finding, S_TC_SM),
    ])

mt = Table(tbl_data, colWidths=[14*mm, 35*mm, 28*mm, 22*mm, 61*mm])
cmds = [
    ("BACKGROUND", (0,0), (-1,0), DARK_NAVY),
    ("GRID", (0,0), (-1,-1), 0.3, HexColor("#BDBDBD")),
    ("TOPPADDING", (0,0), (-1,-1), 4),
    ("BOTTOMPADDING", (0,0), (-1,-1), 4),
    ("LEFTPADDING", (0,0), (-1,-1), 4),
    ("VALIGN", (0,0), (-1,-1), "TOP"),
]
for i, r in enumerate(master_rows, 1):
    cmds.append(("BACKGROUND", (0,i), (-1,i), row_bg_map.get(i, WHITE)))
mt.setStyle(TableStyle(cmds))
story.append(mt)
story.append(Spacer(1, 5*mm))

# ── UPDATED TEACHING POINTS ───────────────────────────────────────────────
story += info_box(
    "🔄  How This Evidence Updates Classic FMGE Teaching",
    [Paragraph(t, S_BULLET) for t in [
        "• OLD: \"Appendicitis always requires surgery\" → NEW: Antibiotics are a valid option for ADULT uncomplicated appendicitis (55.7% avoid surgery at 10 years, JAMA 2026)",
        "• UNCHANGED: In CHILDREN, appendicectomy remains standard (Lancet 2025: antibiotics failed 34% at 1 year)",
        "• OLD: \"T1aN0M0 PTC = total thyroidectomy\" → NEW: Thermal ablation equally effective with less permanent RLN injury (ENT J 2026)",
        "• UNCHANGED: FNAC cannot diagnose follicular thyroid carcinoma — hemithyroidectomy still required",
        "• OLD: \"Give fluids aggressively in trauma shock\" → NEW: RESTRICTIVE fluids recommended for hemorrhagic trauma (ESICM 2025 guideline)",
        "• NEW CONCEPT: REBOA is superior to resuscitative thoracotomy in hemorrhagic shock (J Trauma 2026)",
        "• OLD: \"Partial nephrectomy only for T1a (≤4 cm) RCC\" → NEW: Evidence supports PN even for pT3a RCC (J Robot Surg 2026)",
        "• UNCHANGED: Synthetic mesh is still standard for inguinal hernia repair; laparoscopic approach preferred",
    ]],
    bg=AMBER_LIGHT, border=AMBER_DARK
)

# ── Disclaimer ────────────────────────────────────────────────────────────
story.append(HRFlowable(width=W-72, thickness=0.5, color=GREY_MID))
story.append(Spacer(1, 3*mm))
story.append(Paragraph(
    "All papers verified on PubMed (July 2026). FMGE implications are the author's analysis of "
    "clinical significance for examination preparation. Always cross-reference with current "
    "clinical guidelines and standard surgical textbooks (Bailey &amp; Love, Schwartz's, ATLS Manual). "
    "Compiled by Orris Medical AI for educational use only.",
    S_FOOTER))

# ── Build ─────────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=cover_page, onLaterPages=inner_page)
print(f"Done: {OUTPUT}")