const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Pulmonary Thromboembolism: Diagnosis & Management";
pres.author = "Harrison's Principles of Internal Medicine 22E";

// ──────────────────────────────────────────────────────────
// COLOR PALETTE
// Deep navy bg: #0B1D3A  |  Accent teal: #00B4D8
// Slide bg light: #F0F4F8 |  Text dark: #1A2B4A
// Section accent: #E63946 (alert red)  |  Gold: #F4A261
// ──────────────────────────────────────────────────────────

const NAVY   = "0B1D3A";
const TEAL   = "00B4D8";
const RED    = "E63946";
const GOLD   = "F4A261";
const WHITE  = "FFFFFF";
const LIGHT  = "F0F4F8";
const DARK   = "1A2B4A";
const GRAY   = "7B8FA6";
const GREEN  = "2DC653";

// ──────────────────────────────────────────────────────────
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// ══════════════════════════════════════════════════════════
// SLIDE 1 — TITLE
// ══════════════════════════════════════════════════════════
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  const s = pres.addSlide();
  s.background = { color: NAVY };

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    x: 7.5, y: 0, w: 2.5, h: 5.625,
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  s.addText("PULMONARY", {
    x: 0.6, y: 1.2, w: 7.5, h: 0.7,
    fontSize: 38, bold: true, color: WHITE, margin: 0
  });
  s.addText("THROMBOEMBOLISM", {
    x: 0.6, y: 1.85, w: 7.5, h: 0.7,
    fontSize: 38, bold: true, color: TEAL, margin: 0
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    x: 0.6, y: 3.45, w: 8, h: 0.35,
    fontSize: 12, color: GRAY, italic: true, margin: 0
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  s.addText("Davidson's Principles and Practice of Medicine", {
    x: 0.6, y: 3.78, w: 8, h: 0.35,
    fontSize: 12, color: GRAY, italic: true, margin: 0
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 2 — OVERVIEW & CLASSIFICATION
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Classification of Pulmonary Embolism", NAVY);

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  const boxes = [
    { label: "MASSIVE (High-Risk)", pct: "5-10%", bg: RED, items: [
      "Systemic arterial hypotension",
      "Extensive thrombosis (≥50% pulmonary vasculature)",
      "Dyspnea, syncope, hypotension, cyanosis",
      "Cardiogenic shock → multi-organ failure",
    ]},
    { label: "SUBMASSIVE (Intermediate-Risk)", pct: "20-25%", bg: GOLD, items: [
      "Normal systemic BP but RV dysfunction",
      "RV failure + elevated cardiac biomarkers",
      "Elevated troponin → RV microinfarction",
      "High risk of clinical deterioration",
    ]},
    { label: "LOW-RISK", pct: "65-75%", bg: GREEN, items: [
      "Normal BP and RV function",
      "Excellent prognosis",
      "May be suitable for outpatient treatment",
      "Early discharge protocols applicable",
    ]},
  ];

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    ], {
      x, y: 0.75, w: 3.1, h: 1.1,
      align: "center", valign: "middle", margin: 5
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  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.3, w: 10, h: 0.3,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 3 — PATHOPHYSIOLOGY & RISK FACTORS
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Pathophysiology & Risk Factors", NAVY);

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    x: 0.15, y: 0.75, w: 4.5, h: 4.6,
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    x: 0.2, y: 0.8, w: 4.4, h: 0.4,
    fontSize: 14, bold: true, color: TEAL, margin: 5
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  const triad = [
    ["1. Venous Stasis", "Immobility, prolonged bed rest, long-haul flights, CHF, paralysis"],
    ["2. Endothelial Injury", "Surgery, trauma, central venous catheters, inflammation"],
    ["3. Hypercoagulability", "Malignancy, thrombophilia (Factor V Leiden, protein C/S deficiency, antiphospholipid syndrome), pregnancy, OCP use"],
  ];

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    s.addText(h, { x: 0.3, y: ty, w: 4.2, h: 0.28, fontSize: 12, bold: true, color: DARK, margin: 0 });
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    s.addText(d, { x: 0.35, y: ty, w: 4.1, h: 0.5, fontSize: 10.5, color: GRAY, margin: 0 });
    ty += 0.58;
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    x: 4.85, y: 0.75, w: 5.0, h: 4.6,
    fill: { color: WHITE },
    line: { color: GOLD, width: 1.5 },
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  });
  s.addText("Additional Risk Factors & DVT Origin", {
    x: 4.9, y: 0.8, w: 4.8, h: 0.4,
    fontSize: 14, bold: true, color: GOLD, margin: 5
  });

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    bulletB("DVT Origin"),
    sub("Lower extremity: calf → popliteal → femoral → iliac"),
    sub("Leg DVT ~10× more common than upper extremity DVT"),
    sub("Upper limb DVT: pacemakers, ICD leads, central lines"),
    bulletB("Other Precipitants"),
    sub("Obesity, age >60, varicose veins"),
    sub("Pacemaker/ICD/central venous catheter"),
    sub("Malignancy (trousseau syndrome)"),
    sub("May-Thurner syndrome (recurrent left thigh DVT in young women)"),
    bulletB("Superficial Vein Thrombosis"),
    sub("Erythema, tenderness, palpable cord"),
    sub("Risk of extension to deep system"),
  ];

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  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.3, w: 10, h: 0.3,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 4 — CLINICAL EVALUATION
// ══════════════════════════════════════════════════════════
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  s.background = { color: LIGHT };
  addHeaderBand(s, "Clinical Evaluation: 'The Great Masquerader'", RED);

  // Symptoms
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    x: 0.15, y: 0.75, w: 4.7, h: 4.6,
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  s.addText("Symptoms & Signs", {
    x: 0.2, y: 0.8, w: 4.5, h: 0.38,
    fontSize: 14, bold: true, color: RED, margin: 5
  });
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    bulletB("PE Symptoms"),
    sub("Most common: unexplained breathlessness"),
    sub("Pleuritic chest pain, haemoptysis"),
    sub("Syncope (in massive PE)"),
    sub("Cyanosis, tachycardia, hypotension"),
    bulletB("DVT Symptoms"),
    sub("Calf cramp/'charley horse' that intensifies"),
    sub("Thigh swelling, tenderness, erythema (massive DVT)"),
    sub("Phlegmasia cerulea dolens: diffuse leg edema with cyanosis"),
    bulletB("PE Clinical Clue"),
    sub("No improvement in CHF or pneumonia despite appropriate treatment"),
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    fontSize: 13, bold: true, color: TEAL, margin: 5
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    ["Clinical signs/symptoms of DVT", "+3"],
    ["PE most likely diagnosis", "+3"],
    ["HR > 100 bpm", "+1.5"],
    ["Immobilization ≥3 days / surgery in past 4 wks", "+1.5"],
    ["Previous DVT or PE", "+1.5"],
    ["Haemoptysis", "+1"],
    ["Malignancy (on treatment / last 6 months)", "+1"],
  ];
  const scores = [["0-1", "Low"], ["2-6", "Moderate"], [">6", "High"]];

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    s.addText(score, { x: 8.95, y: ty, w: 0.7, h: 0.4, fontSize: 11, bold: true, color: RED, valign: "middle", align: "center", margin: 0 });
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    s.addText(`${score} pts → ${label} probability`, { x: 5.15, y: ty2, w: 4.5, h: 0.25, fontSize: 10.5, color: DARK, margin: 3 });
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    fontSize: 10, bold: true, color: RED, margin: 3
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  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.3, w: 10, h: 0.3,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 5 — BLOOD TESTS (D-dimer, Troponin, BNP)
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Diagnostic Investigations: Blood Tests", TEAL);

  const cards = [
    {
      title: "D-Dimer", icon: "🔬", col: TEAL,
      lines: [
        "High-sensitivity ELISA preferred",
        "Normal D-dimer (<500 ng/mL): safely excludes PE in low/moderate probability patients",
        "Elevated in: PE, DVT, MI, pneumonia, sepsis, cancer (low specificity)",
        "Age-adjusted threshold: age × 10 ng/mL in patients >50 yrs",
        "Patients on anticoagulants: D-dimer may be falsely low",
      ]
    },
    {
      title: "Troponin (I or T)", icon: "❤️", col: RED,
      lines: [
        "Elevated due to RV microinfarction",
        "Indicates intermediate-to-high risk PE",
        "Guides escalation to thrombolysis",
        "Most elevated in massive PE",
        "Normal troponin = more favorable prognosis",
      ]
    },
    {
      title: "BNP / NT-proBNP", icon: "📈", col: GOLD,
      lines: [
        "Elevated due to right ventricular strain/dilatation",
        "Correlates with RV dysfunction severity",
        "Useful in risk stratification with troponin",
        "Combined troponin + BNP elevation = very high risk",
        "May guide intensity of monitoring/treatment",
      ]
    },
  ];

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      x, y: 0.75, w: 3.1, h: 0.55,
      fontSize: 14, bold: true, color: WHITE, align: "center", valign: "middle", margin: 0
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    const items = card.lines.map((l, j) => ({
      text: l,
      options: { bullet: { type: "bullet" }, breakLine: j < card.lines.length - 1, fontSize: 11.5, color: DARK }
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      x, y: 1.32, w: 3.1, h: 3.95,
      fill: { color: WHITE }, line: { color: card.col, width: 1 }, rectRadius: 0.05
    });
    s.addText(items, { x: x + 0.05, y: 1.35, w: 3.0, h: 3.85, valign: "top", margin: 8 });
  });

  // ABG note
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    x: 0.15, y: 5.12, w: 9.7, h: 0.38,
    fill: { color: "FFF3CD" }, line: { color: GOLD, width: 1 }, rectRadius: 0.05
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  s.addText("ABG: Hypoxemia (↓PaO₂), hypocapnia (↓PaCO₂), ↑Alveolar-arterial O₂ gradient. ECG: Sinus tachycardia most common; S1Q3T3 pattern; new RBBB; T-wave inversions V1-V4", {
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    fontSize: 10, color: DARK, valign: "middle", margin: 3
  });

  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.55, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 6 — IMAGING: CT PULMONARY ANGIOGRAPHY
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Imaging Investigations: CT Pulmonary Angiography (CTPA)", NAVY);

  s.addShape(pres.ShapeType.rect, {
    x: 0.15, y: 0.75, w: 9.7, h: 4.6,
    fill: { color: WHITE }, line: { color: NAVY, width: 1.5 }, rectRadius: 0.1
  });

  const ctItems = [
    bulletB("CTPA — Gold Standard for PE Diagnosis"),
    sub("Test of choice: rapid, non-invasive, widely available"),
    sub("Directly visualizes thrombus in pulmonary arteries"),
    sub("Sensitivity: ~83% | Specificity: ~96%"),
    bullet(""),
    bulletB("CTPA Findings in PE"),
    sub("Intraluminal filling defect (main diagnostic criterion)"),
    sub("RV enlargement (RV/LV diameter ratio >0.9 on axial cut)"),
    sub("'Hampton's hump': peripheral wedge-shaped opacity (pulmonary infarct)"),
    sub("'Westermark sign': oligemia distal to embolus"),
    sub("Dilated main pulmonary artery (>29 mm)"),
    bullet(""),
    bulletB("Limitations"),
    sub("Contrast contraindicated: renal impairment (eGFR <30), severe allergy"),
    sub("Subsegmental PE may be missed on inadequate-quality CT"),
    sub("Radiation exposure (consider in pregnancy — use V/Q instead)"),
    bullet(""),
    bulletB("CT Venography (CTV)"),
    sub("Can be combined with CTPA in same study (one contrast injection)"),
    sub("Detects DVT from iliac veins to popliteal veins"),
    sub("Additional radiation dose: weigh risks vs benefits"),
  ];

  s.addText(ctItems, {
    x: 0.25, y: 0.82, w: 9.5, h: 4.45,
    valign: "top", margin: 8
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  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.42, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 7 — OTHER IMAGING: VQ, ECHO, MRI, Angio
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Imaging Investigations: V/Q Scan, Echo, MRI, Angiography", NAVY);

  const modalities = [
    {
      title: "V/Q Lung Scan", col: TEAL,
      lines: [
        "Preferred when CTPA contraindicated (renal failure, contrast allergy, pregnancy)",
        "High-probability scan: ≥2 segmental perfusion defects with normal ventilation → ~90% diagnostic",
        "Normal/near-normal scan: PE very unlikely",
        "Indeterminate: requires further workup",
      ]
    },
    {
      title: "Echocardiography", col: RED,
      lines: [
        "NOT a reliable primary diagnostic tool (most PE: normal echo)",
        "McConnell's sign: RV free wall hypokinesis + normal/hyperkinetic RV apex (PE-specific)",
        "Rules out mimics: acute MI, cardiac tamponade, aortic dissection",
        "Detects RV dysfunction → risk stratification",
        "Thrombus rarely seen directly in main PA",
      ]
    },
    {
      title: "MRI / MR Venography", col: GOLD,
      lines: [
        "MR venography: excellent for DVT when leg US equivocal",
        "Gadolinium contrast required",
        "MR pulmonary angiography: detects large proximal PE only",
        "NOT reliable for segmental/subsegmental PE",
        "Role mainly in pregnancy or renal failure",
      ]
    },
    {
      title: "Pulmonary Angiography", col: NAVY,
      lines: [
        "Invasive gold standard (now largely replaced by CTPA)",
        "Reserved for: technically poor CTPA, planned catheter intervention",
        "Diagnostic: intraluminal filling defect in ≥2 projections",
        "Secondary signs: vessel cut-off, oligemia, avascularity, slow filling",
      ]
    },
  ];

  modalities.forEach((m, i) => {
    const x = (i % 2 === 0) ? 0.1 : 5.05;
    const y = (i < 2) ? 0.75 : 3.18;
    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.75, h: 2.25,
      fill: { color: WHITE }, line: { color: m.col, width: 1.5 }, rectRadius: 0.08
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    s.addShape(pres.ShapeType.rect, {
      x, y, w: 4.75, h: 0.42,
      fill: { color: m.col }, line: { color: m.col, width: 0 }, rectRadius: 0.08
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      fontSize: 12.5, bold: true, color: WHITE, align: "center", valign: "middle", margin: 0
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      text: l,
      options: { bullet: { type: "bullet" }, breakLine: j < m.lines.length - 1, fontSize: 10.5, color: DARK }
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    s.addText(items, { x: x + 0.05, y: y + 0.45, w: 4.65, h: 1.75, valign: "top", margin: 6 });
  });

  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.45, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 8 — ULTRASONOGRAPHY (DVT detection)
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Venous Ultrasonography & Integrated Diagnostic Approach", TEAL);

  // Left: US
  s.addShape(pres.ShapeType.rect, {
    x: 0.1, y: 0.75, w: 4.7, h: 4.6,
    fill: { color: WHITE }, line: { color: TEAL, width: 1.5 }, rectRadius: 0.1
  });
  s.addText("Compression Ultrasonography (CUS)", {
    x: 0.15, y: 0.8, w: 4.55, h: 0.4,
    fontSize: 13, bold: true, color: TEAL, margin: 5
  });
  s.addText([
    bulletB("Principal diagnostic test for DVT (replaced contrast phlebography)"),
    bullet(""),
    bulletB("Technique"),
    sub("Lack of compressibility of vein = DVT"),
    sub("Two-point compression: common femoral + popliteal veins"),
    sub("Extended to calf if proximal negative"),
    bullet(""),
    bulletB("Findings suggesting DVT"),
    sub("Non-compressible vein segment"),
    sub("Echogenic intraluminal material"),
    sub("Absent flow on colour Doppler"),
    sub("Loss of normal respiratory flow variation"),
    bullet(""),
    bulletB("Limitations"),
    sub("Calf DVT: sensitivity ~73% (limited)"),
    sub("Iliac DVT: poor visibility (bowel gas)"),
    sub("Obesity may reduce image quality"),
    sub("Operator-dependent"),
    bullet(""),
    bullet("Contrast phlebography: used when intervention is planned"),
  ], { x: 0.2, y: 1.25, w: 4.5, h: 4.0, valign: "top", margin: 6 });

  // Right: Integrated approach
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    x: 5.05, y: 0.75, w: 4.8, h: 4.6,
    fill: { color: WHITE }, line: { color: GOLD, width: 1.5 }, rectRadius: 0.1
  });
  s.addText("Integrated Diagnostic Algorithm", {
    x: 5.1, y: 0.8, w: 4.6, h: 0.4,
    fontSize: 13, bold: true, color: GOLD, margin: 5
  });
  s.addText([
    bulletB("Step 1: Assess clinical probability"),
    sub("Use Wells criteria for PE or DVT"),
    bullet(""),
    bulletB("Step 2: D-dimer testing"),
    sub("Low/moderate probability → D-dimer ELISA"),
    sub("Normal D-dimer → PE/DVT excluded"),
    sub("Elevated D-dimer → proceed to imaging"),
    bullet(""),
    bulletB("Step 3: Imaging"),
    sub("High probability → skip D-dimer, go to imaging directly"),
    sub("CTPA: first-line imaging in most patients"),
    sub("V/Q scan: contrast CI, pregnancy, renal failure"),
    sub("Leg CUS: if DVT suspected or CTPA inconclusive"),
    bullet(""),
    bulletB("Step 4: If indeterminate"),
    sub("MR venography / pulmonary MRA"),
    sub("Invasive pulmonary angiography (pre-intervention)"),
    bullet(""),
    bulletB("Risk stratify ALL confirmed PE"),
    sub("Echo + troponin + BNP → guides management intensity"),
  ], { x: 5.1, y: 1.25, w: 4.6, h: 4.0, valign: "top", margin: 6 });

  s.addText("Source: Harrison's 22E, Chapter 290 — Fig 290-14", {
    x: 0, y: 5.42, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 9 — MANAGEMENT: ANTICOAGULATION
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Management: Anticoagulation Strategies", NAVY);

  // Header label
  s.addText("Three Major Anticoagulation Strategies (Harrison's 22E)", {
    x: 0.15, y: 0.72, w: 9.7, h: 0.3,
    fontSize: 12, bold: true, color: NAVY, margin: 0
  });

  const strategies = [
    {
      num: "1", title: "Parenteral → Warfarin Bridge", col: TEAL,
      lines: [
        "UFH or LMWH or Fondaparinux as initial therapy",
        "Bridge to warfarin (INR target 2–3)",
        "Waning strategy — largely replaced by DOACs",
        "Still used in: antiphospholipid syndrome, pregnancy, renal failure",
      ]
    },
    {
      num: "2", title: "Parenteral → DOAC (Sequential)", col: GOLD,
      lines: [
        "Parenteral anticoagulation × 5 days",
        "Then switch to Dabigatran (direct thrombin inhibitor)",
        "Or switch to Edoxaban (anti-Xa agent)",
        "HIT management: Argatroban (IV) or Bivalirudin (IV) or Fondaparinux (SC)",
      ]
    },
    {
      num: "3", title: "Oral DOAC Monotherapy", col: GREEN,
      lines: [
        "Rivaroxaban: 15 mg BD × 3 weeks, then 20 mg OD",
        "Apixaban: 10 mg BD × 1 week, then 5 mg BD",
        "Both are anti-Xa agents",
        "Preferred in most patients (no bridging required)",
      ]
    },
  ];

  strategies.forEach((st, i) => {
    const y = 1.1 + i * 1.4;
    s.addShape(pres.ShapeType.rect, {
      x: 0.1, y, w: 9.8, h: 1.3,
      fill: { color: WHITE }, line: { color: st.col, width: 1.5 }, rectRadius: 0.08
    });
    s.addShape(pres.ShapeType.rect, {
      x: 0.1, y, w: 0.45, h: 1.3,
      fill: { color: st.col }, line: { color: st.col, width: 0 }, rectRadius: 0.08
    });
    s.addText(st.num, {
      x: 0.1, y, w: 0.45, h: 1.3,
      fontSize: 20, bold: true, color: WHITE, align: "center", valign: "middle", margin: 0
    });
    s.addText(st.title, {
      x: 0.65, y: y + 0.02, w: 4.0, h: 0.38,
      fontSize: 12.5, bold: true, color: st.col, margin: 3
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    const items = st.lines.map((l, j) => ({
      text: l,
      options: { bullet: { type: "bullet" }, breakLine: j < st.lines.length - 1, fontSize: 11, color: DARK }
    }));
    s.addText(items, { x: 0.65, y: y + 0.38, w: 9.1, h: 0.88, valign: "top", margin: 5 });
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  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.4, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 10 — UFH & LMWH DETAILS
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Anticoagulation Details: UFH, LMWH, Fondaparinux", NAVY);

  const agents = [
    {
      name: "Unfractionated Heparin (UFH)", col: NAVY,
      lines: [
        "Mechanism: binds antithrombin → prevents thrombus propagation",
        "Dosing: bolus 60 U/kg IV + infusion 18 U/kg/hr (normal liver function)",
        "Target aPTT: 60–80 s (chromogenic anti-Xa 0.3–0.7 U/mL)",
        "Anti-Xa assay preferred in: critically ill, APS, pregnancy, suspected heparin resistance",
        "Advantage: short half-life → hour-to-hour anticoagulation control",
        "Pleiotropic effects: may reduce systemic inflammation",
      ]
    },
    {
      name: "Low-Molecular-Weight Heparins (LMWH)", col: TEAL,
      lines: [
        "Greater bioavailability, predictable dose response, longer half-life vs UFH",
        "Subcutaneous administration; no routine monitoring needed",
        "Dose adjustment required: marked obesity, CKD",
        "Examples: Enoxaparin 1 mg/kg SC BD or 1.5 mg/kg SC OD",
        "Does not cause HIT as commonly as UFH",
      ]
    },
    {
      name: "Fondaparinux", col: GOLD,
      lines: [
        "Ultra-low molecular weight: synthetic anti-Xa pentasaccharide",
        "Weight-based once-daily SC injection (pre-filled syringe)",
        "No lab monitoring required",
        "NOT derived from animal products",
        "Does NOT cause heparin-induced thrombocytopenia (HIT)",
        "Safe in HIT patients",
      ]
    },
  ];

  agents.forEach((ag, i) => {
    const y = 0.75 + i * 1.55;
    s.addShape(pres.ShapeType.rect, {
      x: 0.1, y, w: 9.8, h: 1.45,
      fill: { color: WHITE }, line: { color: ag.col, width: 1.5 }, rectRadius: 0.08
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    s.addText(ag.name, {
      x: 0.2, y: y + 0.05, w: 9.5, h: 0.35,
      fontSize: 13, bold: true, color: ag.col, margin: 3
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    const items = ag.lines.map((l, j) => ({
      text: l,
      options: { bullet: { type: "bullet" }, breakLine: j < ag.lines.length - 1, fontSize: 11, color: DARK }
    }));
    s.addText(items, { x: 0.2, y: y + 0.42, w: 9.5, h: 0.95, valign: "top", margin: 5 });
  });

  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.44, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 11 — DURATION OF ANTICOAGULATION + IVC FILTER
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Duration of Anticoagulation & IVC Filter", NAVY);

  // Left: Duration
  s.addShape(pres.ShapeType.rect, {
    x: 0.1, y: 0.75, w: 4.75, h: 4.6,
    fill: { color: WHITE }, line: { color: TEAL, width: 1.5 }, rectRadius: 0.1
  });
  s.addText("Duration of Anticoagulation", {
    x: 0.15, y: 0.8, w: 4.6, h: 0.4,
    fontSize: 13.5, bold: true, color: TEAL, margin: 5
  });
  s.addText([
    bulletB("3 months (provoked PE — reversible risk factor)"),
    sub("Surgery, trauma, immobilization"),
    sub("Re-evaluate at 3 months"),
    bullet(""),
    bulletB("3–6 months (first unprovoked PE)"),
    sub("Extended treatment considered based on bleeding risk"),
    sub("Low bleeding risk → indefinite treatment favored"),
    bullet(""),
    bulletB("Indefinite / Long-term"),
    sub("Recurrent unprovoked VTE"),
    sub("Active malignancy (use LMWH or anti-Xa DOAC)"),
    sub("Antiphospholipid syndrome"),
    sub("Inherited thrombophilia (e.g. Protein C/S deficiency, Factor V Leiden)"),
    bullet(""),
    bulletB("Extended therapy options"),
    sub("Rivaroxaban 10 mg OD (extended prophylaxis)"),
    sub("Apixaban 2.5 mg BD (after initial 6 months)"),
    sub("Aspirin if anticoagulation stopped"),
  ], { x: 0.2, y: 1.25, w: 4.55, h: 4.0, valign: "top", margin: 5 });

  // Right: IVC filter + Post-thrombotic syndrome
  s.addShape(pres.ShapeType.rect, {
    x: 5.05, y: 0.75, w: 4.8, h: 4.6,
    fill: { color: WHITE }, line: { color: RED, width: 1.5 }, rectRadius: 0.1
  });
  s.addText("IVC Filter & Complications", {
    x: 5.1, y: 0.8, w: 4.65, h: 0.4,
    fontSize: 13.5, bold: true, color: RED, margin: 5
  });
  s.addText([
    bulletB("IVC Filter Indications"),
    sub("Recurrent PE despite adequate anticoagulation"),
    sub("Absolute contraindication to anticoagulation"),
    sub("Massive PE: prevent haemodynamic compromise from further emboli"),
    bullet(""),
    bulletB("IVC Filter Types"),
    sub("Permanent filter: when anticoagulation is permanently contraindicated"),
    sub("Retrievable filter: preferred when indication is temporary"),
    bullet(""),
    bulletB("Post-Phlebitic (Post-Thrombotic) Syndrome"),
    sub("Due to chronic venous obstruction from DVT"),
    sub("Manifestations: chronic leg edema, venous ulcers, skin changes"),
    sub("Compression stockings: 30–40 mmHg; replace every 3–6 months"),
    sub("NOTE: stockings do NOT prevent post-thrombotic syndrome in asymptomatic DVT"),
    bullet(""),
    bulletB("Catheter-Directed Thrombolysis (CDT) for DVT"),
    sub("ATTRACT trial: no overall reduction in post-thrombotic syndrome"),
    sub("Trend benefit in iliofemoral DVT subgroup"),
    sub("Mechanical treatments may have selective role"),
  ], { x: 5.1, y: 1.25, w: 4.65, h: 4.0, valign: "top", margin: 5 });

  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.42, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 12 — FIBRINOLYSIS / THROMBOLYSIS
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Advanced Management: Fibrinolysis / Systemic Thrombolysis", RED);

  s.addShape(pres.ShapeType.rect, {
    x: 0.1, y: 0.75, w: 9.8, h: 4.7,
    fill: { color: WHITE }, line: { color: RED, width: 1.5 }, rectRadius: 0.1
  });

  s.addText([
    bulletB("Indications for Fibrinolysis"),
    sub("MANDATORY: Massive PE with haemodynamic instability (cardiogenic shock, SBP <90 mmHg)"),
    sub("CONSIDER: Submassive PE with clinical deterioration despite anticoagulation"),
    sub("Goal: rapid clot lysis and restoration of pulmonary blood flow"),
    bullet(""),
    bulletB("Approved Fibrinolytic Agents"),
    sub("Alteplase (tPA): 100 mg IV over 2 hours — standard regimen"),
    sub("Streptokinase: 250,000 IU loading dose → 100,000 IU/hr × 24 hrs"),
    sub("Urokinase: 4400 IU/kg/hr × 12–24 hrs"),
    sub("Tenecteplase: weight-based single IV bolus"),
    bullet(""),
    bulletB("Contraindications to Systemic Fibrinolysis"),
    sub("ABSOLUTE: Recent intracranial surgery/trauma, active intracranial neoplasm, prior intracranial haemorrhage"),
    sub("ABSOLUTE: Active internal bleeding (excluding menstruation)"),
    sub("RELATIVE: Recent surgery/biopsy (<10 days), uncontrolled HTN (SBP >185 mmHg)"),
    sub("RELATIVE: CPR for >10 minutes, pregnancy, age >75 years"),
    bullet(""),
    bulletB("Outcomes"),
    sub("Rapid restoration of haemodynamics in massive PE"),
    sub("Mortality benefit established in massive PE with shock"),
    sub("For submassive PE: reduces clinical deterioration but increased bleeding risk"),
    sub("PEITHO trial: tenecteplase reduced haemodynamic collapse but ↑ major bleeding"),
  ], {
    x: 0.2, y: 0.82, w: 9.6, h: 4.5,
    valign: "top", margin: 8
  });

  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.52, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 13 — CATHETER-BASED & SURGICAL INTERVENTIONS
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Catheter-Based Therapy & Surgical Embolectomy", NAVY);

  // Left: CDT
  s.addShape(pres.ShapeType.rect, {
    x: 0.1, y: 0.75, w: 4.75, h: 4.6,
    fill: { color: WHITE }, line: { color: TEAL, width: 1.5 }, rectRadius: 0.1
  });
  s.addText("Catheter-Directed Therapy (CDT)", {
    x: 0.15, y: 0.8, w: 4.6, h: 0.4,
    fontSize: 13, bold: true, color: TEAL, margin: 5
  });
  s.addText([
    bulletB("Indications"),
    sub("Massive PE: fibrinolysis failed or contraindicated"),
    sub("Submassive PE: RV dysfunction + high risk"),
    sub("Bridge to further therapy"),
    bullet(""),
    bulletB("Techniques"),
    sub("Catheter-directed thrombolysis (CDT): intraclot infusion of thrombolytic"),
    sub("Ultrasound-assisted CDT: ultrasound enhances thrombolytic penetration"),
    sub("Large-bore aspiration: FlowTriever (Inari Medical), CAT12 (Penumbra)"),
    sub("Mechanical fragmentation + aspiration"),
    bullet(""),
    bulletB("Outcomes"),
    sub("Success rate: 80–90%"),
    sub("Major complications: 2–4%"),
    sub("Lower systemic bleeding vs full-dose systemic lysis"),
    bullet(""),
    bulletB("PERT (PE Response Team)"),
    sub("Multidisciplinary approach: pulmonology, cardiology, IR, cardiac surgery"),
    sub("Individualized decision-making for each patient"),
  ], { x: 0.2, y: 1.25, w: 4.55, h: 4.0, valign: "top", margin: 5 });

  // Right: Surgery + Supportive
  s.addShape(pres.ShapeType.rect, {
    x: 5.05, y: 0.75, w: 4.8, h: 4.6,
    fill: { color: WHITE }, line: { color: NAVY, width: 1.5 }, rectRadius: 0.1
  });
  s.addText("Surgical Embolectomy & Haemodynamic Support", {
    x: 5.1, y: 0.8, w: 4.65, h: 0.4,
    fontSize: 12.5, bold: true, color: NAVY, margin: 5
  });
  s.addText([
    bulletB("Surgical Pulmonary Embolectomy"),
    sub("Indication: massive PE + haemodynamic instability"),
    sub("Reserved for: fibrinolysis CI or failure, CDT failure"),
    sub("Open surgical removal via cardiopulmonary bypass"),
    sub("Mortality: 20–50% (high-risk but life-saving option)"),
    bullet(""),
    bulletB("Haemodynamic Support"),
    sub("IV fluid resuscitation: cautious (limited RV preload tolerance)"),
    sub("Vasopressors: norepinephrine preferred for RV support"),
    sub("Inotropes: dobutamine for severe RV failure"),
    sub("Impella CP: percutaneous LV support (L-R shunting risk)"),
    bullet(""),
    bulletB("ECMO (VA-ECMO)"),
    sub("Peripheral ECMO via femoral artery & vein"),
    sub("Useful for PE-induced cardiac/respiratory failure"),
    sub("Bridge to definitive therapy (embolectomy, CDT)"),
    sub("Can be placed emergently in cath lab"),
    bullet(""),
    bulletB("Oxygen Therapy"),
    sub("Supplemental O₂ to maintain SpO₂ >94%"),
    sub("Intubation avoided if possible (reduces RV preload)"),
  ], { x: 5.1, y: 1.25, w: 4.65, h: 4.0, valign: "top", margin: 5 });

  s.addText("Source: Harrison's 22E — Interventional Cardiology Chapter + Chapter 290", {
    x: 0, y: 5.42, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 14 — ACUTE MANAGEMENT ALGORITHM
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Acute Management Algorithm (Based on Harrison's Fig. 290-15)", RED);

  // Central Flow
  const addBox = (x, y, w, h, text, bgColor, textColor, fontSize = 11) => {
    s.addShape(pres.ShapeType.rect, {
      x, y, w, h,
      fill: { color: bgColor }, line: { color: NAVY, width: 1 }, rectRadius: 0.08
    });
    s.addText(text, { x, y, w, h, fontSize, bold: true, color: textColor, align: "center", valign: "middle", margin: 4 });
  };

  const addArrow = (x, y, h) => {
    s.addShape(pres.ShapeType.line, {
      x, y, w: 0, h,
      line: { color: NAVY, width: 1.5, endArrowType: "arrow" }
    });
  };

  // PE Confirmed box
  addBox(3.5, 0.72, 3, 0.52, "CONFIRMED PULMONARY EMBOLISM", NAVY, WHITE, 11);
  addArrow(5, 1.24, 0.28);

  // Two branches
  addBox(0.2, 1.6, 4.1, 0.52, "HYPOTENSION / SHOCK\n(Massive / High-Risk PE)", RED, WHITE, 10.5);
  addBox(5.7, 1.6, 4.1, 0.52, "NORMOTENSION\n(Sub-massive / Low-Risk PE)", GREEN, WHITE, 10.5);

  // Branch arrows from top
  s.addShape(pres.ShapeType.line, { x: 5, y: 1.52, w: -2.7, h: 0.08, line: { color: NAVY, width: 1.5 } });
  s.addShape(pres.ShapeType.line, { x: 5, y: 1.52, w: 2.7, h: 0.08, line: { color: NAVY, width: 1.5 } });
  s.addShape(pres.ShapeType.line, { x: 2.3, y: 1.52, w: 0, h: 0.08, line: { color: NAVY, width: 1.5, endArrowType: "arrow" } });
  s.addShape(pres.ShapeType.line, { x: 7.7, y: 1.52, w: 0, h: 0.08, line: { color: NAVY, width: 1.5, endArrowType: "arrow" } });

  // Left branch items
  const leftItems = [
    ["Systemic Thrombolysis\n(Alteplase 100 mg/2 hr)", RED, WHITE],
    ["If fibrinolysis CI or fails:\nCatheter Embolectomy / CDT", TEAL, WHITE],
    ["If CDT fails:\nSurgical Embolectomy\n(± ECMO bridge)", NAVY, WHITE],
    ["IVC Filter: if anticoagulation CI", "607D8B", WHITE],
  ];

  leftItems.forEach(([text, bg, fg], i) => {
    addArrow(2.25, 2.2 + i * 0.9, 0.2);
    addBox(0.2, 2.4 + i * 0.9, 4.1, 0.7, text, bg, fg, 10);
  });

  // Right branch items
  const rightItems = [
    ["Anticoagulation\n(DOAC or Heparin ± Warfarin)", GREEN, WHITE],
    ["Risk Stratify:\nEcho + Troponin + BNP", TEAL, WHITE],
    ["Submassive + deterioration:\nConsider CDT / thrombolysis", GOLD, DARK],
    ["Low-risk:\nConsider outpatient treatment", "43A047", WHITE],
  ];

  rightItems.forEach(([text, bg, fg], i) => {
    addArrow(7.75, 2.2 + i * 0.9, 0.2);
    addBox(5.7, 2.4 + i * 0.9, 4.1, 0.7, text, bg, fg, 10);
  });

  s.addText("Source: Harrison's 22E, Chapter 290 — Fig 290-15", {
    x: 0, y: 5.45, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 15 — SUMMARY TABLE
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: LIGHT };
  addHeaderBand(s, "Summary: Investigations at a Glance", TEAL);

  const rows = [
    ["Investigation", "Finding in PE", "Role", "Notes"],
    ["D-Dimer (ELISA)", "Elevated (>500 ng/mL)", "Exclusion (low/mod probability)", "Age-adjusted: age×10 in >50 yrs"],
    ["CTPA", "Intraluminal filling defect", "Gold standard — confirms PE", "First-line imaging; CI if eGFR<30"],
    ["V/Q Scan", "Perfusion defect, normal ventilation", "PE diagnosis (when CTPA CI)", "High-prob = ~90% diagnostic"],
    ["Compression USG", "Non-compressible vein", "DVT diagnosis", "Replaced contrast phlebography"],
    ["Echocardiography", "RV dilatation, McConnell's sign", "Risk stratification; exclude mimics", "Not reliable for diagnosis"],
    ["Troponin I/T", "Elevated", "Risk stratification", "RV microinfarction → poor prognosis"],
    ["BNP/NT-proBNP", "Elevated", "RV strain marker", "Guides treatment intensity"],
    ["ABG", "Hypoxemia, hypocapnia", "Supportive evidence", "↑A-a O₂ gradient"],
    ["ECG", "Sinus tachycardia, S1Q3T3", "Supportive; exclude mimics", "New RBBB, T-inv V1-V4"],
    ["Pulm Angiography", "Intraluminal defect (≥2 projections)", "Gold standard (invasive)", "Reserved for intervention-planned cases"],
    ["MRI", "Thrombus on MR angiography", "DVT/PE in pregnancy or renal failure", "Unreliable for subsegmental PE"],
  ];

  const colW = [2.1, 2.2, 2.5, 3.15];
  const colX = [0.05, 2.15, 4.35, 6.85];
  const rowH = 0.38;
  const startY = 0.72;

  rows.forEach((row, ri) => {
    row.forEach((cell, ci) => {
      const isHeader = ri === 0;
      s.addShape(pres.ShapeType.rect, {
        x: colX[ci], y: startY + ri * rowH, w: colW[ci], h: rowH,
        fill: { color: isHeader ? NAVY : (ri % 2 === 0 ? "E8F4FD" : WHITE) },
        line: { color: "C0C0C0", width: 0.5 }
      });
      s.addText(cell, {
        x: colX[ci] + 0.04, y: startY + ri * rowH, w: colW[ci] - 0.08, h: rowH,
        fontSize: isHeader ? 11 : 9.5,
        bold: isHeader,
        color: isHeader ? WHITE : DARK,
        valign: "middle", margin: 2
      });
    });
  });

  s.addText("Source: Harrison's 22E, Chapter 290", {
    x: 0, y: 5.42, w: 10, h: 0.25,
    fontSize: 9, color: GRAY, italic: true, align: "right", margin: 5
  });
}

// ══════════════════════════════════════════════════════════
// SLIDE 16 — KEY TAKEAWAYS / CONCLUSION
// ══════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  s.background = { color: NAVY };

  s.addShape(pres.ShapeType.rect, {
    x: 0, y: 0, w: 10, h: 0.7,
    fill: { color: TEAL }, line: { color: TEAL, width: 0 }
  });
  s.addText("Key Takeaways", {
    x: 0.15, y: 0, w: 9.7, h: 0.7,
    fontSize: 22, bold: true, color: WHITE, valign: "middle", margin: 0
  });

  const points = [
    ["PE is 'the great masquerader' — always consider it in unexplained dyspnoea.", GOLD],
    ["Use Wells score to stratify: Low/Moderate → D-dimer first; High → imaging directly.", TEAL],
    ["CTPA is the gold standard imaging. V/Q scan for pregnant/renal-failure patients.", WHITE],
    ["Always risk-stratify confirmed PE: Massive / Submassive / Low-risk.", WHITE],
    ["Anticoagulation is mainstay. DOACs (rivaroxaban/apixaban) are now preferred.", TEAL],
    ["Massive PE with shock → systemic thrombolysis ± catheter/surgical embolectomy.", RED],
    ["Troponin + BNP + Echo guide risk stratification and escalation of therapy.", GOLD],
    ["IVC filter only when anticoagulation is absolutely contraindicated or fails.", WHITE],
    ["Duration: 3 months (provoked) → indefinite (recurrent/unprovoked/malignancy).", WHITE],
  ];

  points.forEach(([text, col], i) => {
    const y = 0.82 + i * 0.52;
    s.addShape(pres.ShapeType.rect, {
      x: 0.1, y, w: 0.32, h: 0.35,
      fill: { color: col }, line: { color: col, width: 0 }, rectRadius: 0.05
    });
    s.addText(text, {
      x: 0.55, y, w: 9.3, h: 0.42,
      fontSize: 12, color: WHITE, valign: "middle", margin: 0
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// ══════════════════════════════════════════════════════════
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