multiple sclerosis physical medicine rehabilitation case study symptoms treatment 2024

multiple sclerosis MRI brain lesions demyelination

multiple sclerosis rehabilitation physical therapy exercises

multiple sclerosis pathophysiology demyelination myelin sheath nerve

multiple sclerosis types relapsing remitting secondary progressive

mkdir -p /home/daytona/workspace/ms-rehab-pptx && ls /home/daytona/workspace/ms-…

~/ms-rehab-pptx/build_pptx.js

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ─── Fetch images as base64 ───────────────────────────────────────────────────
const imageUrls = [
  // Slide 2 – MRI/diagnosis
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_672f78c9ca25dd77dce2d71f20dc6b259bef9c1492e3f61a10e034d82f06631a.jpg",
  // Slide 3 – Pathophysiology
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_eb3b658a8849f3c7d36fdf53c1aa9d8dc8f3432c732fd37fefa78a83de18a0e9.jpg",
  // Slide 4 – Types / RRMS
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_4bbacbca176393dc23aad51a6a194660dd37a6f6a268c6112f79be6bf6161837.jpg",
  // Slide 5 – Signs & Symptoms (MRI lesions)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_9c900f79f0a744bb3622285f17238eec399a8d2365df206c4e771463f5973166.jpg",
  // Slide 6 – Diagnosis / McDonald criteria
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_9485887684ab34af4125e9bfc80bee893e0d66f28c8c9d28bdda9752425eaef9.jpg",
  // Slide 7 – Medical management (treatment RRMS lesions)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_3cf075c7cb45d0ca98349cfef3c35517d6d96a5712ce6de4fa5e54ee4c592034.jpg",
  // Slide 8 – Rehabilitation overview (VR/wheelchair)
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_93eb56156e34d062e22936eef0d58306b9311e95194198a0a63eddca32052e63.jpg",
  // Slide 9 – Physical therapy exercises
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_ab3a13015eac585a0447f619c01dee6596e729ad059d15f1f83897758f91a988.jpg",
  // Slide 10 – Robotic/assistive rehab
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_7613e8cc194ff48d419b32a0329deca1887883076180cf9926960019ac3ac9b1.jpg",
  // Slide 12 – Case study imaging
  "https://cdn.orris.care/cdss_images/pmc_clinical_VQA_13bc02e8bf6b401633d8b3927ad10e4a918f7142328f8f6c59f7994f29d87088.jpg",
];

console.log("Fetching images...");
const images = JSON.parse(
  execSync(
    `node /home/daytona/skills/shared/scripts/fetch_images.js ${imageUrls.map(u => `"${u}"`).join(" ")}`,
    { maxBuffer: 50 * 1024 * 1024 }
  ).toString()
);
console.log(`Fetched ${images.length} images. Errors: ${images.filter(i=>i.error).map(i=>i.error)}`);

// ─── Color palette ────────────────────────────────────────────────────────────
const DARK   = "0A1628";   // deep navy (background)
const MID    = "0E2040";   // slightly lighter navy (content bg)
const ACCENT = "00C2FF";   // vibrant cyan
const GOLD   = "F0A500";   // warm gold for highlights
const WHITE  = "FFFFFF";
const LGRAY  = "D0DCF0";
const SGRAY  = "7A9ABB";

let pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author  = "Physical Medicine & Rehabilitation";
pres.title   = "Multiple Sclerosis – PM&R Presentation";

// ─── Helper: full dark background ────────────────────────────────────────────
function darkBg(slide) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:"100%", fill:{color:DARK}, line:{color:DARK} });
}

// ─── Helper: section header bar ──────────────────────────────────────────────
function headerBar(slide, title, sub) {
  slide.addShape(pres.ShapeType.rect, { x:0, y:0, w:"100%", h:1.1, fill:{color:MID}, line:{color:MID} });
  slide.addShape(pres.ShapeType.rect, { x:0, y:1.1, w:"100%", h:0.06, fill:{color:ACCENT}, line:{color:ACCENT} });
  slide.addText(title, { x:0.4, y:0.1, w:9, h:0.75, fontSize:28, bold:true, color:WHITE, fontFace:"Calibri", margin:0 });
  if(sub) slide.addText(sub, { x:0.4, y:0.78, w:8, h:0.3, fontSize:13, color:ACCENT, fontFace:"Calibri", margin:0 });
}

// ─── Helper: bullet block ────────────────────────────────────────────────────
function bullets(slide, items, opts={}) {
  const {x=0.35, y=1.35, w=5.9, h=3.9, fontSize=14, color=LGRAY} = opts;
  const arr = items.map((t,i) => ({
    text: t,
    options: { bullet:{type:"bullet"}, color, fontSize, fontFace:"Calibri", breakLine: i<items.length-1 }
  }));
  slide.addText(arr, { x, y, w, h, valign:"top", paraSpaceAfter:6 });
}

// ─── Helper: content card ────────────────────────────────────────────────────
function card(slide, opts={}) {
  const {x=0.3, y=1.25, w=5.9, h=4.1} = opts;
  slide.addShape(pres.ShapeType.rect, { x, y, w, h, fill:{color:MID}, line:{color:ACCENT, pt:1}, rounding:true });
}

// ─── SLIDE 1 – Title ─────────────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  // Large accent bar
  s.addShape(pres.ShapeType.rect, { x:0, y:0, w:0.18, h:"100%", fill:{color:ACCENT}, line:{color:ACCENT} });
  // Gold decorative bar
  s.addShape(pres.ShapeType.rect, { x:0.18, y:2.3, w:9.6, h:0.06, fill:{color:GOLD}, line:{color:GOLD} });

  s.addText("Multiple Sclerosis", {
    x:0.55, y:0.6, w:9, h:1.4, fontSize:52, bold:true, color:WHITE, fontFace:"Calibri", margin:0
  });
  s.addText("Physical Medicine & Rehabilitation", {
    x:0.55, y:2.1, w:9, h:0.55, fontSize:22, color:ACCENT, fontFace:"Calibri", italic:true, margin:0
  });
  s.addText("Pathophysiology • Diagnosis • Rehabilitation Strategies • Case Study", {
    x:0.55, y:2.55, w:9, h:0.4, fontSize:13, color:SGRAY, fontFace:"Calibri", margin:0
  });
  s.addText("Department of Physical Medicine & Rehabilitation  |  2026", {
    x:0.55, y:4.9, w:9, h:0.35, fontSize:11, color:SGRAY, fontFace:"Calibri", margin:0
  });
}

// ─── SLIDE 2 – What is MS? ────────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "What is Multiple Sclerosis?", "Overview & Epidemiology");
  card(s, {x:0.3, y:1.25, w:5.85, h:4.1});
  bullets(s, [
    "Chronic autoimmune demyelinating disease of the CNS affecting brain, spinal cord, and optic nerves",
    "Prevalence: ~2.8 million people worldwide; most common disabling neurological disease in young adults",
    "Onset typically between ages 20–40; female:male ratio ≈ 3:1",
    "Characterized by periods of relapse (acute attacks) and remission or progressive worsening",
    "Leads to physical, cognitive, and emotional disability over time",
    "PM&R plays a central role in maintaining function, independence & quality of life"
  ], {x:0.5, y:1.4, w:5.5, h:3.9, fontSize:13.5});
  if(images[0] && !images[0].error) {
    s.addImage({ data:images[0].base64, x:6.35, y:1.25, w:3.25, h:4.1, rounding:true });
  }
  s.addText("MRI: Periventricular demyelinating lesions (Dawson's fingers)", {
    x:6.35, y:5.35, w:3.25, h:0.3, fontSize:9, color:SGRAY, fontFace:"Calibri", italic:true, align:"center"
  });
}

// ─── SLIDE 3 – Pathophysiology ────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Pathophysiology", "Immune-Mediated Demyelination");
  card(s, {x:0.3, y:1.25, w:5.85, h:4.1});
  bullets(s, [
    "Autoreactive T-cells (CD4+ Th1 & Th17) breach the blood–brain barrier and attack myelin",
    "B-cells and antibodies target myelin basic protein (MBP) and myelin oligodendrocyte glycoprotein (MOG)",
    "Pro-inflammatory cytokines (TNF-α, IL-1β, IL-17) drive oligodendrocyte destruction",
    "Repeated demyelination → axonal transection → irreversible neurological deficit",
    "Astrocytes form scar tissue (sclerosis = 'plaques') at demyelinated zones",
    "Impaired saltatory conduction slows or blocks nerve signal transmission"
  ], {x:0.5, y:1.4, w:5.5, h:3.9, fontSize:13.5});
  if(images[1] && !images[1].error) {
    s.addImage({ data:images[1].base64, x:6.35, y:1.25, w:3.25, h:4.1, rounding:true });
  }
  s.addText("Herpesvirus-triggered autoimmune cascade targeting myelin", {
    x:6.35, y:5.35, w:3.25, h:0.3, fontSize:9, color:SGRAY, italic:true, align:"center"
  });
}

// ─── SLIDE 4 – Types of MS ────────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Types of Multiple Sclerosis", "Clinical Disease Courses");

  const types = [
    { label:"RRMS", sub:"Relapsing-Remitting", color:ACCENT, desc:"Most common (85%). Defined episodes of neurological deficits with partial or full recovery between relapses." },
    { label:"SPMS", sub:"Secondary Progressive", color:GOLD,  desc:"Follows RRMS; sustained disability progression with or without superimposed relapses." },
    { label:"PPMS", sub:"Primary Progressive",  color:"E05A5A", desc:"Continuous worsening from onset (~15%); no distinct relapses; more equal sex distribution." },
    { label:"PRMS", sub:"Progressive-Relapsing", color:"7BC67E", desc:"Continuous progression from onset with acute relapses; rarest form." },
  ];
  types.forEach((t,i) => {
    const col = i < 2 ? 0.3 : 5.15;
    const row = i % 2 === 0 ? 1.25 : 3.4;
    s.addShape(pres.ShapeType.rect, { x:col, y:row, w:4.6, h:1.9, fill:{color:MID}, line:{color:t.color, pt:1.5}, rounding:true });
    s.addText(t.label, { x:col+0.18, y:row+0.12, w:1.4, h:0.5, fontSize:20, bold:true, color:t.color, fontFace:"Calibri", margin:0 });
    s.addText(t.sub,   { x:col+0.18, y:row+0.56, w:4.2, h:0.3, fontSize:11, color:WHITE, fontFace:"Calibri", margin:0 });
    s.addText(t.desc,  { x:col+0.18, y:row+0.88, w:4.2, h:0.9, fontSize:11.5, color:LGRAY, fontFace:"Calibri", margin:0, wrap:true });
  });
  if(images[2] && !images[2].error) {
    s.addImage({ data:images[2].base64, x:0.3, y:5.1, w:9.3, h:0.42, rounding:false });
  }
}

// ─── SLIDE 5 – Signs & Symptoms ──────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Signs & Symptoms", "Variable Presentation Based on Lesion Location");
  card(s, {x:0.3, y:1.25, w:5.85, h:4.1});
  bullets(s, [
    "Fatigue (most common symptom, ~80% of patients) – often worsening with heat (Uhthoff phenomenon)",
    "Sensory: numbness, tingling, paresthesias; Lhermitte's sign (neck flexion → electric shock down spine)",
    "Motor: limb weakness, spasticity, gait ataxia, foot drop",
    "Visual: optic neuritis (blurred vision, pain on eye movement), diplopia, nystagmus",
    "Bladder/bowel dysfunction: urgency, frequency, neurogenic bladder",
    "Cognitive: memory lapses, slowed processing speed, executive dysfunction",
    "Pain, sexual dysfunction, depression & anxiety are also highly prevalent"
  ], {x:0.5, y:1.4, w:5.5, h:3.9, fontSize:13});
  if(images[3] && !images[3].error) {
    s.addImage({ data:images[3].base64, x:6.35, y:1.25, w:3.25, h:4.1, rounding:true });
  }
  s.addText("Dawson's fingers + cervical cord lesions on T2 MRI", {
    x:6.35, y:5.35, w:3.25, h:0.3, fontSize:9, color:SGRAY, italic:true, align:"center"
  });
}

// ─── SLIDE 6 – Diagnosis ─────────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Diagnosis", "McDonald Criteria 2017 + Investigations");
  card(s, {x:0.3, y:1.25, w:5.85, h:4.1});
  bullets(s, [
    "McDonald Criteria (2017): requires dissemination in space (DIS) AND time (DIT)",
    "MRI: T2/FLAIR hyperintense lesions in periventricular, juxtacortical, infratentorial, or spinal cord regions",
    "Gadolinium-enhancing lesion = active inflammation (new DIT criterion met alone)",
    "CSF analysis: oligoclonal IgG bands (present in >85% of MS patients)",
    "Visual Evoked Potentials (VEPs): prolonged P100 latency in optic neuritis",
    "Expanded Disability Status Scale (EDSS): 0–10 scale to quantify neurological disability",
    "Differential: NMOSD, CNS vasculitis, neurosarcoidosis, vitamin B12 deficiency"
  ], {x:0.5, y:1.4, w:5.5, h:3.9, fontSize:13});
  if(images[4] && !images[4].error) {
    s.addImage({ data:images[4].base64, x:6.35, y:1.25, w:3.25, h:4.1, rounding:true });
  }
  s.addText("FLAIR + diffusion MRI: chronic inactive vs. active plaques", {
    x:6.35, y:5.35, w:3.25, h:0.3, fontSize:9, color:SGRAY, italic:true, align:"center"
  });
}

// ─── SLIDE 7 – Medical Management ────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Medical Management", "Disease-Modifying & Symptomatic Therapies");

  const cols = [
    { title:"Acute Relapse", color:ACCENT, items:["High-dose IV methylprednisolone 1g/day × 3–5 days","Plasma exchange for steroid-refractory relapse","Accelerates recovery; does not alter long-term disability"] },
    { title:"Disease-Modifying Therapy (DMT)", color:GOLD, items:["1st line: IFN-β, glatiramer acetate, dimethyl fumarate, teriflunomide","High efficacy: natalizumab, ocrelizumab, alemtuzumab, cladribine","PPMS: ocrelizumab (only FDA-approved DMT)"] },
    { title:"Symptomatic Treatment", color:"7BC67E", items:["Spasticity: baclofen, tizanidine, intrathecal baclofen pump","Fatigue: amantadine, modafinil; cognitive rehab","Bladder: oxybutynin, intermittent self-catheterization","Pain: gabapentin, pregabalin, amitriptyline"] },
  ];
  cols.forEach((c,i) => {
    const x = 0.25 + i*3.28;
    s.addShape(pres.ShapeType.rect, { x, y:1.25, w:3.1, h:4.1, fill:{color:MID}, line:{color:c.color, pt:1.2}, rounding:true });
    s.addShape(pres.ShapeType.rect, { x, y:1.25, w:3.1, h:0.45, fill:{color:c.color}, line:{color:c.color}, rounding:true });
    s.addText(c.title, { x:x+0.12, y:1.28, w:2.9, h:0.38, fontSize:12.5, bold:true, color:DARK, fontFace:"Calibri", margin:0 });
    const arr = c.items.map((t,j) => ({
      text:t, options:{ bullet:{type:"bullet"}, color:LGRAY, fontSize:12, fontFace:"Calibri", breakLine: j<c.items.length-1 }
    }));
    s.addText(arr, { x:x+0.15, y:1.82, w:2.8, h:3.45, valign:"top", paraSpaceAfter:8 });
  });
  if(images[5] && !images[5].error) {
    s.addImage({ data:images[5].base64, x:0.25, y:5.1, w:9.4, h:0.42 });
  }
}

// ─── SLIDE 8 – Role of PM&R ──────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Role of Physical Medicine & Rehabilitation", "Interdisciplinary Team Approach");
  card(s, {x:0.3, y:1.25, w:5.85, h:4.1});
  bullets(s, [
    "PM&R aims to maximise functional independence, safety, and quality of life",
    "Physiatrist leads the multidisciplinary team (MDT): PT, OT, SLP, psychology, nursing, social work",
    "Goals: reduce spasticity, improve mobility, maintain ADLs, prevent secondary complications",
    "Rehabilitation should be initiated early and reassessed with disease progression",
    "Inpatient rehabilitation indicated for EDSS ≥4 with functional decline or post-relapse",
    "Home exercise program and community re-integration are long-term pillars",
    "Fatigue management (energy conservation) is one of the most important rehabilitation goals"
  ], {x:0.5, y:1.4, w:5.5, h:3.9, fontSize:13.5});
  if(images[6] && !images[6].error) {
    s.addImage({ data:images[6].base64, x:6.35, y:1.25, w:3.25, h:4.1, rounding:true });
  }
  s.addText("VR-assisted rehabilitation enhancing patient engagement", {
    x:6.35, y:5.35, w:3.25, h:0.3, fontSize:9, color:SGRAY, italic:true, align:"center"
  });
}

// ─── SLIDE 9 – Physical Therapy ──────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Physical Therapy", "Exercise, Gait & Balance Rehabilitation");
  card(s, {x:0.3, y:1.25, w:5.85, h:4.1});
  bullets(s, [
    "Aerobic exercise (moderate intensity, 3–5×/week): reduces fatigue, improves cardiovascular fitness",
    "Resistance/strength training: counteracts weakness, reduces fall risk",
    "Balance & coordination training: Frenkel's exercises, Bobath technique, Tai Chi",
    "Gait rehabilitation: treadmill training (body-weight supported), functional electrical stimulation (FES) for foot drop",
    "Aquatic therapy: buoyancy reduces weight-bearing demands; cooler water prevents Uhthoff effect",
    "Cooling strategies (pre-cooling vests) are recommended before exercise sessions",
    "Outcome measures: 6MWT, Timed Up & Go, 25-foot walk test (T25FW)"
  ], {x:0.5, y:1.4, w:5.5, h:3.9, fontSize:13});
  if(images[7] && !images[7].error) {
    s.addImage({ data:images[7].base64, x:6.35, y:1.25, w:3.25, h:4.1, rounding:true });
  }
  s.addText("Hip/knee strengthening exercises used in gait rehabilitation", {
    x:6.35, y:5.35, w:3.25, h:0.3, fontSize:9, color:SGRAY, italic:true, align:"center"
  });
}

// ─── SLIDE 10 – OT & Assistive Technology ────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Occupational Therapy & Assistive Technology", "Adaptive Strategies & Devices");
  card(s, {x:0.3, y:1.25, w:5.85, h:4.1});
  bullets(s, [
    "Energy conservation techniques: pacing, task prioritization, seated work strategies",
    "Upper limb retraining: fine motor tasks, coordination, handwriting adaptations",
    "Home modification assessment: grab rails, bathroom aids, ramp access",
    "Assistive devices: ankle-foot orthoses (AFO), walking aids, motorized scooters, power wheelchairs",
    "Robotic exoskeletons (e.g., Marsi Active Knee) for gait rehabilitation and active support",
    "Driving assessment and vehicle adaptations for continued independence",
    "Cognitive rehabilitation: memory aids, compensatory strategies, smartphone apps"
  ], {x:0.5, y:1.4, w:5.5, h:3.9, fontSize:13});
  if(images[8] && !images[8].error) {
    s.addImage({ data:images[8].base64, x:6.35, y:1.25, w:3.25, h:4.1, rounding:true });
  }
  s.addText("Marsi Active Knee robotic knee orthosis for gait assistance", {
    x:6.35, y:5.35, w:3.25, h:0.3, fontSize:9, color:SGRAY, italic:true, align:"center"
  });
}

// ─── SLIDE 11 – Speech, Bladder & Psychosocial Rehab ─────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Comprehensive Symptomatic Rehabilitation", "SLP • Bladder • Psychosocial Care");

  const cols2 = [
    { title:"Speech-Language Pathology", color:ACCENT, items:["Dysarthria: oral motor exercises, rate reduction","Dysphagia: texture modification, safe swallowing strategies","Cognitive-communication therapy for memory & word-finding"] },
    { title:"Bladder & Bowel Rehab", color:GOLD, items:["Timed voiding schedules reduce urgency incontinence","Pelvic floor exercises (Kegel) for overactive bladder","Bowel program: fiber, fluid intake, scheduled toileting"] },
    { title:"Psychosocial Rehabilitation", color:"7BC67E", items:["Depression in 37–54% of MS patients – CBT + pharmacotherapy","Anxiety management: mindfulness, relaxation training","Peer support groups and MS Society referral (1-800-Fight-MS)","Vocational counselling & workplace adjustments"] },
  ];
  cols2.forEach((c,i) => {
    const x = 0.25 + i*3.28;
    s.addShape(pres.ShapeType.rect, { x, y:1.25, w:3.1, h:4.1, fill:{color:MID}, line:{color:c.color, pt:1.2}, rounding:true });
    s.addShape(pres.ShapeType.rect, { x, y:1.25, w:3.1, h:0.45, fill:{color:c.color}, line:{color:c.color}, rounding:true });
    s.addText(c.title, { x:x+0.1, y:1.28, w:2.9, h:0.38, fontSize:12, bold:true, color:DARK, fontFace:"Calibri", margin:0 });
    const arr = c.items.map((t,j) => ({
      text:t, options:{ bullet:{type:"bullet"}, color:LGRAY, fontSize:12, fontFace:"Calibri", breakLine: j<c.items.length-1 }
    }));
    s.addText(arr, { x:x+0.15, y:1.82, w:2.8, h:3.45, valign:"top", paraSpaceAfter:8 });
  });
}

// ─── SLIDE 12 – Case Study ────────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Case Study", "34-Year-Old Female with RRMS");
  // Top row: two info boxes
  const boxStyle = {fill:{color:MID}, line:{color:ACCENT, pt:1}, rounding:true};
  s.addShape(pres.ShapeType.rect, { x:0.3, y:1.25, w:4.5, h:2.0, ...boxStyle });
  s.addText("Presentation", { x:0.45, y:1.28, w:4, h:0.32, fontSize:13, bold:true, color:ACCENT, margin:0 });
  s.addText([
    {text:"Chief complaint:", options:{bold:true, color:GOLD, breakLine:false}},
    {text:" Right leg weakness, blurred vision OD, fatigue, tingling in both hands × 3 weeks\n", options:{color:LGRAY}},
    {text:"PMHx:", options:{bold:true, color:GOLD, breakLine:false}},
    {text:" Optic neuritis 2 years ago (resolved)\n", options:{color:LGRAY}},
    {text:"Exam:", options:{bold:true, color:GOLD, breakLine:false}},
    {text:" EDSS 3.5 | Right leg ↓power MRC 4/5 | Hyperreflexia | Positive Lhermitte's sign", options:{color:LGRAY}},
  ], { x:0.45, y:1.62, w:4.1, h:1.55, fontSize:11.5, fontFace:"Calibri", valign:"top" });

  s.addShape(pres.ShapeType.rect, { x:5.0, y:1.25, w:4.65, h:2.0, ...boxStyle });
  s.addText("Investigations", { x:5.15, y:1.28, w:4, h:0.32, fontSize:13, bold:true, color:ACCENT, margin:0 });
  s.addText([
    {text:"MRI Brain:", options:{bold:true, color:GOLD, breakLine:false}},
    {text:" Multiple periventricular T2 lesions + 1 Gd-enhancing right frontal lesion\n", options:{color:LGRAY}},
    {text:"MRI Spine:", options:{bold:true, color:GOLD, breakLine:false}},
    {text:" T2 hyperintense lesion at C4\n", options:{color:LGRAY}},
    {text:"CSF:", options:{bold:true, color:GOLD, breakLine:false}},
    {text:" Oligoclonal bands positive (6 bands)\n", options:{color:LGRAY}},
    {text:"VEP:", options:{bold:true, color:GOLD, breakLine:false}},
    {text:" Prolonged P100 latency right eye → McDonald criteria met", options:{color:LGRAY}},
  ], { x:5.15, y:1.62, w:4.45, h:1.55, fontSize:11.5, fontFace:"Calibri", valign:"top" });

  // Image
  if(images[9] && !images[9].error) {
    s.addImage({ data:images[9].base64, x:0.3, y:3.35, w:3.5, h:2.1, rounding:true });
  }

  // Rehab plan box
  s.addShape(pres.ShapeType.rect, { x:3.95, y:3.35, w:5.7, h:2.1, fill:{color:MID}, line:{color:GOLD, pt:1}, rounding:true });
  s.addText("Rehabilitation Plan", { x:4.1, y:3.38, w:5, h:0.3, fontSize:13, bold:true, color:GOLD, margin:0 });
  const planItems = [
    "Acute: IV methylprednisolone 1g/day × 5 days for relapse",
    "DMT initiated: dimethyl fumarate (Tecfidera) 240mg BD",
    "PT: 3×/week – gait training, right leg strengthening, balance exercises",
    "OT: energy conservation, home modification, AFO for foot drop",
    "Psychology: CBT for fatigue and adjustment to diagnosis",
    "MDT review at 4 weeks; goal EDSS reduction to 2.0",
  ];
  const planArr = planItems.map((t,i) => ({
    text:t, options:{bullet:{type:"bullet"}, color:LGRAY, fontSize:11, fontFace:"Calibri", breakLine:i<planItems.length-1}
  }));
  s.addText(planArr, { x:4.1, y:3.7, w:5.4, h:1.7, valign:"top", paraSpaceAfter:3 });
}

// ─── SLIDE 13 – Outcomes & Prognosis ─────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Rehabilitation Outcomes & Prognosis", "Evidence-Based Results");
  card(s, {x:0.3, y:1.25, w:9.3, h:4.1});
  const arr = [
    "Exercise therapy reduces fatigue severity (SMD −0.53) and improves walking speed and quality of life (Class I evidence)",
    "Inpatient rehabilitation produces significant functional gains (FIM scores) even in progressive MS",
    "Physiotherapy improves balance (Berg Balance Scale) and reduces fall risk by up to 30%",
    "Cognitive rehabilitation programs improve memory and attention in ≥60% of MS patients",
    "Bladder retraining programs reduce incontinence episodes by 50–70% in neurogenic bladder",
    "Multidisciplinary rehabilitation reduces hospital re-admissions and slows institutionalisation",
    "Poor prognostic factors: male sex, older age at onset, high lesion load, EDSS ≥5 at 5 years, PPMS subtype",
    "Key principle: rehabilitation does not slow disease progression but MAXIMISES function at every stage"
  ];
  const txtArr = arr.map((t,i) => ({
    text:t, options:{bullet:{type:"bullet"}, color:LGRAY, fontSize:13, fontFace:"Calibri", breakLine:i<arr.length-1}
  }));
  s.addText(txtArr, { x:0.55, y:1.4, w:9.0, h:3.9, valign:"top", paraSpaceAfter:5 });
}

// ─── SLIDE 14 – Summary ───────────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "Summary", "Key Take-Home Messages");

  const cards = [
    { icon:"🧠", label:"Understand the Disease", text:"MS is a chronic autoimmune demyelinating disease with variable clinical courses requiring life-long management.", color:ACCENT },
    { icon:"🔬", label:"Diagnose Accurately", text:"McDonald 2017 criteria use MRI, CSF, and clinical data. Differentiating MS from mimics is critical.", color:GOLD },
    { icon:"💊", label:"Treat with DMTs", text:"Early initiation of disease-modifying therapy reduces relapse rate and delays disability progression.", color:"7BC67E" },
    { icon:"🏃", label:"Rehabilitate Early", text:"PM&R addresses fatigue, mobility, spasticity, cognition & psychosocial wellbeing via an MDT approach.", color:"E05A5A" },
    { icon:"📋", label:"Monitor & Adapt", text:"Serial EDSS + outcome measures guide therapy intensity. Goals shift with disease course.", color:"C77DFF" },
    { icon:"🤝", label:"Empower the Patient", text:"Education, self-management, peer support, and shared decision-making improve long-term outcomes.", color:SGRAY },
  ];
  cards.forEach((c,i) => {
    const col = i < 3 ? 0 : 1;
    const x = 0.3 + (i % 3) * 3.22;
    const y = 1.3 + (i < 3 ? 0 : 2.2);
    s.addShape(pres.ShapeType.rect, { x, y, w:3.05, h:2.0, fill:{color:MID}, line:{color:c.color, pt:1}, rounding:true });
    s.addText(c.icon+" "+c.label, { x:x+0.14, y:y+0.1, w:2.8, h:0.42, fontSize:13.5, bold:true, color:c.color, fontFace:"Calibri", margin:0 });
    s.addText(c.text, { x:x+0.14, y:y+0.54, w:2.8, h:1.35, fontSize:11.5, color:LGRAY, fontFace:"Calibri", valign:"top", wrap:true });
  });
}

// ─── SLIDE 15 – References ────────────────────────────────────────────────────
{
  let s = pres.addSlide();
  darkBg(s);
  headerBar(s, "References", "Selected Sources");
  const refs = [
    "1. Bradley and Daroff's Neurology in Clinical Practice, 8th ed. (2022). Elsevier.",
    "2. McDonald WI et al. Recommended diagnostic criteria for multiple sclerosis: guidelines from the International Panel. Ann Neurol. 2001.",
    "3. Thompson AJ et al. Diagnosis of multiple sclerosis: 2017 revisions of the McDonald criteria. Lancet Neurol. 2018;17(2):162–173.",
    "4. Haselkorn JK et al. Summary of comprehensive systematic review: rehabilitation in multiple sclerosis. Neurology. 2015.",
    "5. Motl RW, Gosney JL. Effect of exercise training on quality of life in multiple sclerosis: a meta-analysis. Mult Scler. 2008.",
    "6. Paltamaa J et al. Effects of physiotherapy on balance in MS: systematic review and meta-analysis. J Rehabil Med. 2012.",
    "7. Braley TJ et al. CBT, modafinil for MS fatigue (COMBO-MS). Lancet Neurol. 2024;23(11):1108–1118.",
    "8. National Multiple Sclerosis Society. www.nationalmssociety.org. Accessed May 2026.",
    "9. Mayo Clinic. Multiple Sclerosis – Diagnosis and Treatment. mayoclinic.org. 2024.",
  ];
  const txtArr = refs.map((r,i) => ({
    text:r, options:{color:LGRAY, fontSize:11.5, fontFace:"Calibri", breakLine:i<refs.length-1}
  }));
  s.addText(txtArr, { x:0.5, y:1.3, w:9.0, h:4.1, valign:"top", paraSpaceAfter:6 });
  s.addShape(pres.ShapeType.rect, { x:0, y:5.35, w:"100%", h:0.28, fill:{color:MID}, line:{color:MID} });
  s.addText("Physical Medicine & Rehabilitation Department  •  Multiple Sclerosis Presentation  •  2026", {
    x:0.3, y:5.37, w:9.3, h:0.24, fontSize:9, color:SGRAY, align:"center", fontFace:"Calibri"
  });
}

// ─── Write file ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/ms-rehab-pptx/Multiple_Sclerosis_PMR.pptx" })
  .then(() => console.log("✅ PPTX saved successfully!"))
  .catch(err => { console.error("❌ Error:", err); process.exit(1); });

cd /home/daytona/workspace/ms-rehab-pptx && node build_pptx.js 2>&1

ls -lh /home/daytona/workspace/ms-rehab-pptx/Multiple_Sclerosis_PMR.pptx

multiple sclerosis MRI brain periventricular lesions FLAIR

multiple sclerosis rehabilitation physical therapy gait training

neurological examination motor weakness spasticity assessment

optic neuritis eye vision blurred multiple sclerosis

cerebrospinal fluid CSF oligoclonal bands electrophoresis

multiple sclerosis spinal cord MRI cervical lesion T2