"diabetic foot ulcer" AND management

ls -la /home/daytona/workspace/ && mkdir -p /home/daytona/workspace/dfu-presenta…

~/dfu-presentation/create_dfu_pptx.js

const pptxgen = require("pptxgenjs");

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pres.layout = "LAYOUT_16x9";
pres.author = "Orris AI";
pres.title = "Diabetic Foot Ulcer";

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// ============================
// SLIDE 1: Title
// ============================
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  slide.addText("DIABETIC FOOT ULCER", {
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  slide.addText("Pathophysiology · Classification · Diagnosis · Management", {
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  slide.addText("A Comprehensive Clinical Review", {
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  slide.addText("Sources: Fischer's Mastery of Surgery 8e · Sabiston Textbook of Surgery · Campbell's Operative Orthopaedics 15e · Current Surgical Therapy 14e", {
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// ============================
// SLIDE 2: Epidemiology & Burden
// ============================
addContentSlide("Epidemiology & Global Burden", [
  { text: "Prevalence & Incidence", bold: true, color: C.amber },
  "~537 million adults worldwide have diabetes (IDF 2021); >6.3% develop foot ulcers annually",
  "Lifetime risk of DFU in diabetic patients: 15-25%",
  "DFU precedes ~85% of all diabetes-related lower extremity amputations",
  { text: "Mortality Burden", bold: true, color: C.amber },
  "5-year mortality after DFU: ~30% — comparable to many cancers",
  "5-year mortality after major amputation: ~50-70%",
  { text: "Economic Impact", bold: true, color: C.amber },
  "US: estimated $327 billion total cost of diabetes annually",
  "Excess medical costs >$9,000 per diabetic patient per year",
  "DFU management accounts for a disproportionate share of diabetes expenditure",
]);

// ============================
// SLIDE 3: Risk Factors
// ============================
addTwoColSlide(
  "Risk Factors for Diabetic Foot Ulcer",
  "Patient-Level Factors",
  [
    "Peripheral neuropathy (loss of protective sensation)",
    "Peripheral arterial disease (PAD)",
    "Poor glycemic control (HbA1c >7%)",
    "Duration of diabetes >10 years",
    "Diabetic nephropathy / renal disease",
    "Retinopathy (marker of microvascular damage)",
    "Obesity (BMI > 30)",
    "Male sex",
    "Smoking and alcohol use",
    "Prior history of foot ulceration or amputation",
  ],
  "Foot-Level Factors",
  [
    "Foot deformities: claw foot, hammer toe, bunion",
    "Callus formation at pressure points",
    "Limited joint mobility",
    "Abnormal plantar pressure distribution",
    "Dry, cracked skin (autonomic neuropathy)",
    "Onychomycosis / nail pathology",
    "Ill-fitting footwear",
    "Inadequate foot hygiene",
    "Minor trauma (unnoticed due to neuropathy)",
  ]
);

// ============================
// SLIDE 4: Pathophysiology Overview
// ============================
addContentSlide("Pathophysiology: The Triad", [
  { text: "1. Peripheral Neuropathy (most important)", bold: true, color: C.amber },
  "Sorbitol/fructose accumulation → impaired ATPase → axonal structural breakdown",
  "Oxidative stress from mitochondrial free radical production → nerve damage",
  "Glycosylation of vasa nervorum basement membrane → ischemia → nerve fiber loss",
  "Starts with small unmyelinated fibers → progresses to larger fibers",
  { text: "2. Peripheral Arterial Disease (macrovascular)", bold: true, color: C.amber },
  "Arteriosclerosis → reduced blood flow → impaired wound healing",
  "Often multisegmental; tibial and peroneal arteries commonly affected",
  { text: "3. Foot Deformity & Abnormal Pressure", bold: true, color: C.amber },
  "Motor neuron damage → intrinsic muscle wasting → clawfoot / hammer toe",
  "Abnormal plantar pressure points → repetitive trauma → ulceration (especially great toe, 5th metatarsal head)",
]);

// ============================
// SLIDE 5: Neuropathy in Detail
// ============================
addTwoColSlide(
  "Neuropathy: Sensory, Motor & Autonomic",
  "Sensory Neuropathy",
  [
    "Loss of protective sensation (LOPS)",
    "Glove-and-stocking distribution",
    "Numbness, paresthesias, pain",
    "Unnoticed minor injuries → ulceration",
    "Assessed by 10-g Semmes-Weinstein monofilament",
    "Confirmed by: pinprick, temperature, vibration, proprioception",
  ],
  "Motor & Autonomic Neuropathy",
  [
    "Motor: intrinsic muscle wasting → deformity",
    "Clawfoot, hammer toe → abnormal pressure points",
    "Gait abnormalities: increased step width, poor balance",
    "Autonomic: decreased sweating → dry, cracked skin",
    "Skin fissuring → portal of entry for infection",
    "Arteriovenous shunting → warm foot despite ischemia",
  ]
);

// ============================
// SLIDE 6: Vascular Disease in DFU
// ============================
addContentSlide("Peripheral Arterial Disease in DFU", [
  { text: "Prevalence", bold: true, color: C.amber },
  "PAD present in 40-60% of DFU patients; frequently underdiagnosed",
  "Coexistence of neuropathy masks ischemic symptoms (painless ischemia)",
  { text: "Assessment", bold: true, color: C.amber },
  "Ankle-Brachial Index (ABI): <0.9 diagnostic of PAD; >1.3 suggests calcification (non-compressible)",
  "Toe-Brachial Index (TBI): preferred in diabetics — <0.7 abnormal",
  "Transcutaneous oxygen pressure (TcPO2): <30 mmHg indicates critical ischemia",
  "CT Angiography / MR Angiography: for revascularization planning",
  { text: "WiFi Classification — Ischemia Component", bold: true, color: C.amber },
  "Grade 0: ABI ≥0.8, TBI ≥0.6 | Grade 1: ABI 0.6-0.79, TBI 0.4-0.59",
  "Grade 2: ABI 0.4-0.59, TBI 0.25-0.39 | Grade 3: ABI <0.4, TBI <0.25",
]);

// ============================
// SLIDE 7: Classification - Wagner
// ============================
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    { grade: "Grade 0", desc: "Pre-ulcerative lesion, healed ulcer, bony deformity", color: C.green },
    { grade: "Grade 1", desc: "Superficial ulcer — skin or subcutaneous tissue only", color: "2980B9" },
    { grade: "Grade 2", desc: "Ulcer extends to tendon, capsule, or bone", color: "8E44AD" },
    { grade: "Grade 3", desc: "Deep ulcer with abscess, osteomyelitis, or joint sepsis", color: C.amber },
    { grade: "Grade 4", desc: "Forefoot gangrene (focal gangrene ± infection)", color: "E74C3C" },
    { grade: "Grade 5", desc: "Whole foot gangrene (extensive necrosis)", color: "922B21" },
  ];

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// ============================
// SLIDE 8: University of Texas & SINBAD
// ============================
addContentSlide("University of Texas (UT) & SINBAD Classification", [
  { text: "University of Texas Classification", bold: true, color: C.amber },
  "Two dimensions: Stage (A-D) × Grade (0-3)",
  "Grade 0: pre/post-ulcer | Grade 1: superficial | Grade 2: tendon/capsule | Grade 3: bone/joint",
  "Stage A: clean wound | Stage B: infected | Stage C: ischemic | Stage D: infected + ischemic",
  "Amputation and healing outcomes worsen from stage A→D",
  { text: "SINBAD Score (0-6)", bold: true, color: C.amber },
  "S - Site: forefoot (0) vs. midfoot/hindfoot (1)",
  "I - Ischemia: pedal flow intact (0) vs. reduced (1)",
  "N - Neuropathy: protective sensation present (0) vs. absent (1)",
  "B - Bacterial infection: none (0) vs. present (1)",
  "A - Area: <1 cm² (0) vs. ≥1 cm² (1)",
  "D - Depth: skin/subcutaneous (0) vs. tendon/deeper (1)",
  "SINBAD score ≥3 predicts poor healing outcomes",
]);

// ============================
// SLIDE 9: WiFi Classification
// ============================
addContentSlide("WIfI Classification System (Society for Vascular Surgery)", [
  { text: "Components: Wound + Ischemia + foot Infection", bold: true, color: C.amber },
  "Each component graded 0 (none) to 3 (severe) → 64 possible permutations",
  "Predicts 1-year risk of major limb amputation and benefit of revascularization",
  "Validated for all lower extremity threatened limb, including DFU",
  "Advanced WIfI stage correlates with: prolonged healing, decreased 1-year amputation-free survival",
  { text: "Wound Grade", bold: true, color: C.amber },
  "W0: no ulcer/gangrene | W1: small shallow ulcer | W2: deeper ulcer, exposed bone/tendon | W3: extensive deep ulcer or gangrene",
  { text: "Ischemia Grade", bold: true, color: C.amber },
  "I0: ABI ≥0.8 (no ischemia) | I1-3: progressive reduction in ABI/TBI with I3 = critical ischemia",
  { text: "foot Infection Grade (IDSA/IWGDF based)", bold: true, color: C.amber },
  "fI0: no infection | fI1: mild (skin only) | fI2: moderate (deep tissue) | fI3: severe (systemic signs)",
]);

// ============================
// SLIDE 10: Clinical Assessment
// ============================
addContentSlide("Clinical Evaluation: A Three-Level Approach", [
  { text: "Level 1: The Patient as a Whole", bold: true, color: C.amber },
  "Glycemic control: HbA1c, fasting glucose — optimize preoperatively and throughout",
  "Cardiovascular risk: hypertension, dyslipidemia, smoking cessation",
  "Nutritional status: albumin, prealbumin — critical for wound healing",
  "Immunological status: leukocyte count, immune function",
  { text: "Level 2: The Affected Limb", bold: true, color: C.amber },
  "Neuropathy: 10-g monofilament + vibration tuning fork (128 Hz) + pinprick + temperature",
  "Vascularity: pulses (dorsalis pedis, posterior tibial), ABI, TBI, duplex ultrasound",
  "Structural deformity: hallux valgus, hammer/claw toes, Charcot neuroarthropathy",
  { text: "Level 3: The Wound", bold: true, color: C.amber },
  "Infection: purulence or ≥2 signs of inflammation (erythema, warmth, tenderness, pain, swelling)",
  "Depth: superficial vs. deep — probe-to-bone test (specificity ~89% for osteomyelitis)",
  "Osteomyelitis: positive probe-to-bone, elevated ESR/CRP/WBC, MRI (most sensitive)",
]);

// ============================
// SLIDE 11: Wound Assessment & Probe-to-Bone
// ============================
addContentSlide("Wound Examination: Key Steps", [
  { text: "Initial Callus Debridement", bold: true, color: C.amber },
  "Overriding callus obscures the wound — always debride before assessment",
  "Callus increases underlying tissue pressure and blocks wound edge epithelialization",
  { text: "Wound Characteristics", bold: true, color: C.amber },
  "Location: plantar forefoot (metatarsal heads), hallux, heel (different etiologies and prognosis)",
  "Size (area and depth), shape, undermining, sinus tracts",
  "Wound bed: granulation, slough, eschar, biofilm",
  "Surrounding skin: maceration, callus, erythema, induration",
  { text: "Probe-to-Bone (PTB) Test", bold: true, color: C.amber },
  "Sterile stainless-steel probe to wound depth — 'click' on striking bone = positive",
  "Positive PTB has sensitivity ~66%, specificity ~85% for osteomyelitis",
  "Recurrent or deepening ulcers should raise high suspicion for osteomyelitis",
  { text: "MRI for Osteomyelitis", bold: true, color: C.amber },
  "Most sensitive modality (sensitivity ~90%, specificity ~80%)",
  "Gold standard short of bone biopsy — guides surgical planning",
]);

// ============================
// SLIDE 12: Diagnosing Infection (IDSA/IWGDF)
// ============================
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    { sev: "Uninfected", criteria: "No signs or symptoms of infection", idsa: "Grade 1", mgmt: "No antibiotics; wound care", color: C.green },
    { sev: "Mild", criteria: "≥2 signs of inflammation; erythema <2 cm from wound; superficial only", idsa: "Grade 2", mgmt: "Oral antibiotics targeting S. aureus/Streptococci", color: "2980B9" },
    { sev: "Moderate", criteria: "Deeper infection (tendon, joint, bone, fascia) OR erythema >2 cm from wound", idsa: "Grade 3", mgmt: "IV/oral antibiotics; surgical evaluation", color: C.amber },
    { sev: "Severe", criteria: "Any diabetic foot infection with systemic signs (fever, leukocytosis, hemodynamic instability)", idsa: "Grade 4", mgmt: "IV antibiotics; urgent surgical debridement; hospitalize", color: C.crimson },
  ];

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  slide.addText("Management Approach", { x: 6.0, y: 0.73, w: 3.85, h: 0.25, fontSize: 11, bold: true, color: C.light, fontFace: "Calibri" });
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// ============================
// SLIDE 13: Microbiology & Antibiotics
// ============================
addTwoColSlide(
  "Microbiology & Antibiotic Therapy",
  "Common Pathogens",
  [
    "MILD: Gram-positive cocci dominate",
    "  - S. aureus (including MRSA)",
    "  - Beta-hemolytic Streptococci",
    "MODERATE-SEVERE: Polymicrobial",
    "  - Gram-negative: Pseudomonas, Enterobacteriaceae",
    "  - Anaerobes (in necrotic, ischemic wounds)",
    "MRSA risk factors: prior hospitalization, prior antibiotic use, nasal carriage",
    "Deep cultures via unbroken skin or bone biopsy preferred",
    "Surface swabs NOT recommended (poor specificity)",
  ],
  "Antibiotic Selection",
  [
    "Mild: oral anti-staph/strep",
    "  - Amoxicillin-clavulanate",
    "  - Clindamycin (if penicillin-allergic)",
    "  - TMP-SMX or doxycycline (for MRSA coverage)",
    "Moderate: IV ± oral",
    "  - Piperacillin-tazobactam",
    "  - Cefoxitin, ertapenem",
    "Severe / MRSA: IV",
    "  - Vancomycin + piperacillin-tazobactam",
    "  - Daptomycin (if vancomycin-resistant)",
    "Duration: until signs of infection resolve (2-4 weeks for soft tissue; 4-6 wks for osteomyelitis)",
  ]
);

// ============================
// SLIDE 14: Off-loading
// ============================
addContentSlide("Off-loading: The Cornerstone of DFU Management", [
  { text: "Why Off-loading?", bold: true, color: C.amber },
  "Neuropathic ulcers result from repeated mechanical trauma at pressure points",
  "Continued weight-bearing prevents healing even with best wound care",
  "Reduces plantar pressure → removes primary etiology for neuropathic DFU",
  { text: "Total Contact Cast (TCC) — Gold Standard", bold: true, color: C.amber },
  "Distributes pressure evenly across entire plantar surface",
  "Non-removable = enforced compliance (major advantage over removable devices)",
  "Heals ~90% of plantar neuropathic ulcers within 6-8 weeks",
  "Contraindications: severe ischemia, active deep infection, uncontrolled skin maceration",
  { text: "Alternative Off-loading Devices", bold: true, color: C.amber },
  "Removable cast walker (RCW) — effective if compliant; renders TCC equivalent when made irremovable",
  "Forefoot-relief footwear (post-op shoe) — for hindfoot ulcers only",
  "Pressure-relieving insoles — Oxford leather shoes with replaceable insoles (every 4-6 months) for prevention",
  "Surgical correction of deformity: Achilles tendon lengthening, metatarsal head resection — reduces recurrence",
]);

// ============================
// SLIDE 15: Wound Care
// ============================
addCardSlide("Wound Care Principles", [
  {
    title: "Debridement",
    bullets: [
      "Sharp/surgical: removes necrotic tissue, stimulates wound bed",
      "Enzymatic: collagenase for sloughy wounds",
      "Wet-to-dry dressings (classic nonsurgical)",
      "Maggot therapy: selective, not faster than standard"
    ]
  },
  {
    title: "Dressings",
    bullets: [
      "Moist environment to promote re-epithelialization",
      "Control exudate, prevent maceration",
      "Saline/Vaseline gauze: low cost, daily or BID",
      "Silver-impregnated: antimicrobial properties",
      "Foam/hydrocolloid: for moderate exudate"
    ]
  },
  {
    title: "Negative Pressure Wound Therapy (NPWT)",
    bullets: [
      "Vacuum sponge 2-3x/week changes",
      "Debrides superficial tissue, reduces bacterial load",
      "Promotes angiogenesis and granulation tissue",
      "Meta-analysis 2025 (Angulo et al.): faster wound closure vs standard care",
      "Infusion VAC: instills antibiotics/saline"
    ]
  },
  {
    title: "Growth Factors & Advanced Therapies",
    bullets: [
      "Topical PDGF (becaplermin): for wounds failing standard therapy",
      "Platelet-rich plasma (PRP): promotes healing via growth factors",
      "Hyperbaric oxygen therapy (HBOT): for well-perfused wounds",
      "Increases tissue O2, promotes angiogenesis",
      "Photodynamic therapy: emerging (meta-analysis Hou et al. 2024)"
    ]
  }
]);

// ============================
// SLIDE 16: Revascularization
// ============================
addContentSlide("Revascularization in Ischemic DFU", [
  { text: "Indications", bold: true, color: C.amber },
  "ABI <0.6 or TcPO2 <30 mmHg with non-healing wound",
  "Chronic limb-threatening ischemia (CLTI) — WIfI ischemia grade 2-3",
  "Failed conservative wound management despite adequate off-loading and infection control",
  { text: "Pre-operative Imaging", bold: true, color: C.amber },
  "CT angiography: preferred — detailed runoff vessel assessment",
  "MR angiography: alternative (avoids radiation, good soft tissue detail)",
  "Duplex ultrasound: first-line non-invasive; operator dependent",
  { text: "Revascularization Options", bold: true, color: C.amber },
  "Endovascular (PTA ± stenting): preferred for tibial/peroneal disease; lower morbidity",
  "Bypass surgery (vein preferred): better long-term patency for longer occlusions",
  "Hybrid procedures: combination endovascular + surgical",
  { text: "Outcomes", bold: true, color: C.amber },
  "Successful revascularization significantly reduces amputation rates",
  "WIfI ischemia grade guides likelihood of benefit from revascularization",
]);

// ============================
// SLIDE 17: Surgical Management & Amputation
// ============================
addTwoColSlide(
  "Surgical Management",
  "Debridement & Minor Procedures",
  [
    "Surgical debridement: grossly infected or necrotic wounds",
    "Metatarsal head resection: for grade 1 forefoot ulcers under bony prominences",
    "Achilles tendon lengthening: reduces forefoot plantar pressure, decreases recurrence",
    "Sesamoidectomy, condylectomy: for focal bony prominences",
    "Probe-to-bone positive → evaluate for surgical bone excision",
    "Bone biopsy: gold standard for osteomyelitis diagnosis",
  ],
  "Amputation Levels",
  [
    "Digital/ray amputation: toe or ray with metatarsal segment",
    "Transmetatarsal amputation (TMA): mid-forefoot; good function if viable",
    "Syme amputation: through ankle; preserves limb length",
    "Below-knee (BK) amputation: most common major amputation",
    "Above-knee (AK) amputation: for extensive proximal disease",
    "5-year mortality post-major amputation: 50-70%",
    "Multidisciplinary team essential for rehabilitation planning",
  ]
);

// ============================
// SLIDE 18: Osteomyelitis Management
// ============================
addContentSlide("Osteomyelitis in Diabetic Foot", [
  { text: "Diagnosis", bold: true, color: C.amber },
  "Clinical suspicion: deepening ulcer, visible/palpable bone, sinus tract, chronic non-healing wound",
  "Probe-to-bone test: positive test has high predictive value",
  "Lab markers: ESR >70 mm/hr, CRP elevation (non-specific but supportive)",
  "MRI: best imaging modality (sensitivity ~90%, specificity ~80%)",
  "Bone biopsy with culture: definitive diagnosis — guides targeted antibiotic therapy",
  { text: "Treatment: Medical vs. Surgical", bold: true, color: C.amber },
  "Conservative: prolonged antibiotics (6-12 weeks) for non-surgical candidates",
  "Surgical: preferred when possible — resect involved bone → shorter antibiotic course",
  "Avoid surface swab cultures — unreliable, should not guide antibiotic choice",
  { text: "Antibiotic Duration", bold: true, color: C.amber },
  "Post-surgical with clear margins: 2-5 days",
  "Residual infected bone: 4-6 weeks total",
  "No surgery: 3-6 months (controversial, evidence limited)",
]);

// ============================
// SLIDE 19: Charcot Neuroarthropathy
// ============================
addContentSlide("Charcot Neuroarthropathy (Charcot Foot)", [
  { text: "Definition", bold: true, color: C.amber },
  "Progressive destruction of bone, joints, soft tissue of the foot/ankle in neuropathic patients",
  "Results from repetitive trauma on insensate foot + autonomic neuropathy (increased blood flow → bone resorption)",
  { text: "Clinical Presentation", bold: true, color: C.amber },
  "Warm, swollen, erythematous foot — often mistaken for infection or DVT",
  "Painless (due to neuropathy) — key differentiating feature",
  "Rocker-bottom deformity: midfoot collapse (classic late finding)",
  "Temperature difference >2°C between feet highly suggestive",
  { text: "Diagnosis", bold: true, color: C.amber },
  "X-ray: fragmentation, dislocation, sclerosis, periarticular new bone",
  "MRI: early marrow edema before radiographic changes",
  "Bone scan: increased uptake (not specific)",
  { text: "Management", bold: true, color: C.amber },
  "Acute phase: strict non-weight-bearing — TCC until skin temperature normalizes",
  "Chronic phase: accommodative footwear with custom insoles",
  "Surgery: for unstable deformity causing recurrent ulceration (arthrodesis, exostectomy)",
]);

// ============================
// SLIDE 20: Multidisciplinary Team
// ============================
addCardSlide("Multidisciplinary Team Approach", [
  {
    title: "Endocrinology / Diabetologist",
    bullets: [
      "Optimize glycemic control (HbA1c target <7-8%)",
      "Adjust insulin regimens",
      "Manage other diabetes complications",
      "Long-term diabetes care coordination"
    ]
  },
  {
    title: "Vascular Surgery / Interventional Radiology",
    bullets: [
      "ABI/TBI assessment and vascular imaging",
      "Endovascular or surgical revascularization",
      "CLTI management and limb salvage",
      "WIfI-guided treatment planning"
    ]
  },
  {
    title: "Podiatry / Orthopaedics",
    bullets: [
      "Wound debridement and local care",
      "Off-loading prescription (TCC, footwear)",
      "Surgical correction of deformities",
      "Management of Charcot neuroarthropathy"
    ]
  },
  {
    title: "Infectious Disease / Microbiology",
    bullets: [
      "MRSA screening and management",
      "Antibiotic selection and stewardship",
      "Bone biopsy interpretation",
      "Prolonged antibiotic therapy monitoring"
    ]
  }
]);

// ============================
// SLIDE 21: Prevention
// ============================
addContentSlide("Prevention: Reducing DFU Risk", [
  { text: "Patient Education (ALL diabetic patients)", bold: true, color: C.amber },
  "Daily foot inspection — use mirror or caregiver for plantar surface",
  "Wash feet in lukewarm water, dry thoroughly especially between toes",
  "Never walk barefoot; inspect shoes before wearing",
  "Moisturize (not between toes); trim nails straight across",
  { text: "Footwear & Pressure Relief", bold: true, color: C.amber },
  "Oxford leather shoes with laces; avoid narrow toe box",
  "Pressure-relieving insoles: replace every 4-6 months for high-risk patients",
  "Therapeutic footwear: Medicare covers for high-risk diabetics",
  { text: "Surveillance by Risk Category", bold: true, color: C.amber },
  "Low risk (no neuropathy, no PAD): annual foot exam by provider",
  "Moderate risk (neuropathy OR PAD): exam every 6 months",
  "High risk (neuropathy + PAD or deformity): exam every 3-4 months",
  "Very high risk (prior ulcer or amputation): exam every 1-3 months",
  { text: "Glycemic & Cardiovascular Optimization", bold: true, color: C.amber },
  "HbA1c <7% → significantly reduces microvascular complications including neuropathy",
  "Blood pressure control, statins, smoking cessation",
]);

// ============================
// SLIDE 22: Emerging & Advanced Therapies
// ============================
addContentSlide("Emerging Therapies in DFU Management", [
  { text: "Bioengineered Skin Substitutes", bold: true, color: C.amber },
  "Acellular dermal matrices, bilayer skin substitutes (Apligraf, Dermagraft)",
  "Provide scaffold for wound healing; FDA-approved for DFU",
  { text: "Photodynamic Therapy (PDT)", bold: true, color: C.amber },
  "Uses photosensitizing agents + light to kill bacteria and stimulate healing",
  "2024 meta-analysis (Hou et al.): PDT significantly improves DFU healing rates",
  { text: "Low-Level Laser Therapy (LLLT)", bold: true, color: C.amber },
  "Biostimulatory effects on fibroblasts and keratinocytes",
  "2025 umbrella review (Miranda et al.): modest evidence for adjunct use",
  { text: "Extracorporeal Shockwave Therapy (ESWT)", bold: true, color: C.amber },
  "Promotes angiogenesis, reduces biofilm, stimulates growth factors",
  "2025 meta-analysis (Ruiz-Munoz et al.): significant improvement in wound healing in chronic DFU",
  { text: "Stem Cell Therapy & Growth Factors", bold: true, color: C.amber },
  "Mesenchymal stem cells: promote angiogenesis and wound healing (early-phase trials)",
  "EGF, FGF, VEGF topical formulations — under active investigation",
  "Autologous PRP: emerging evidence supports use as adjunct therapy",
]);

// ============================
// SLIDE 23: Key Evidence Summary
// ============================
addContentSlide("Key Evidence: Recent Systematic Reviews (2023-2025)", [
  { text: "Off-loading", bold: true, color: C.amber },
  "TCC remains gold standard — superior healing rates vs. removable devices (Cochrane evidence)",
  { text: "NPWT (Negative Pressure Wound Therapy)", bold: true, color: C.amber },
  "Angulo et al. 2025 (Meta-analysis): NPWT superior to standard care in wound healing and closure in DFU",
  { text: "Photodynamic Therapy", bold: true, color: C.amber },
  "Hou et al. 2024 (Meta-analysis, PMID 38866070): PDT significantly improves DFU outcomes",
  { text: "Low-Level Laser Therapy", bold: true, color: C.amber },
  "Miranda et al. 2025 (Umbrella review, PMID 39982518): moderate evidence for adjunct LLLT",
  { text: "Extracorporeal Shockwave Therapy", bold: true, color: C.amber },
  "Ruiz-Munoz et al. 2025 (Meta-analysis, PMID 41133500): ESWT effective for chronic DFU",
  { text: "Risk Factor Meta-analysis", bold: true, color: C.amber },
  "Tang et al. 2024 (Systematic Review, PMID 36740805): neuropathy, PAD, glycemic control = strongest modifiable risk factors",
  { text: "Classification & Outcomes", bold: true, color: C.amber },
  "WIfI classification validated as best predictor of 1-year amputation risk and revascularization benefit",
]);

// ============================
// SLIDE 24: Summary & Take-Home Points
// ============================
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    "DFU = triad of neuropathy + PAD + mechanical deformity — address all three",
    "Assess at three levels: patient (glycemia), limb (vascular/neuro), wound (infection/depth)",
    "WIfI classification best predicts amputation risk and need for revascularization",
    "Probe-to-bone + MRI for osteomyelitis; bone biopsy for definitive microbiology",
    "Off-loading (TCC) is the single most important treatment for neuropathic DFU",
    "Infection severity guides antibiotic route; avoid swab cultures — use deep/bone cultures",
    "Revascularize before wound closure in ischemic wounds (ABI <0.6 / TcPO2 <30 mmHg)",
    "Multidisciplinary team (endocrine, vascular, podiatry, ID) improves limb salvage rates",
    "5-year mortality post-DFU rivals many cancers — aggressive management is warranted",
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// ============================
// Write file
// ============================
pres.writeFile({ fileName: "/home/daytona/workspace/dfu-presentation/Diabetic_Foot_Ulcer.pptx" })
  .then(() => console.log("✅ Presentation saved!"))
  .catch(err => console.error("❌ Error:", err));

cd /home/daytona/workspace/dfu-presentation && node create_dfu_pptx.js

ls -lh /home/daytona/workspace/dfu-presentation/