priapism management treatment

ls -la /home/daytona/workspace/ 2>/dev/null || echo "workspace empty or not acce…

mkdir -p /home/daytona/workspace/priapism-ppt && ls /home/daytona/workspace/pria…

~/priapism-ppt/priapism.js

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

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.title = "Priapism - Comprehensive Clinical Review";

// ─── COLOR PALETTE ───────────────────────────────────────────────
const C = {
  navy:     "0D2B4E",  // dominant dark
  teal:     "1A7A8A",  // supporting
  skyBlue:  "4FB3CC",  // accent light
  white:    "FFFFFF",
  offWhite: "F2F7FA",
  lightGray:"E8EEF2",
  amber:    "E8A320",  // highlight / warning
  red:      "C0392B",  // danger / ischemic
  green:    "1E7E5A",  // non-ischemic / safe
  darkText: "1A1A2E",
  midText:  "2C3E50",
};

// ─── HELPERS ─────────────────────────────────────────────────────
function darkSlide(slide) {
  slide.background = { color: C.navy };
}
function lightSlide(slide) {
  slide.background = { color: C.offWhite };
}
function sectionBand(slide, label, color) {
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  slide.addText(label.toUpperCase(), {
    x: 0.25, y: 0, w: 9.5, h: 0.55,
    fontSize: 11, bold: true, color: C.white, valign: "middle", margin: 0,
    charSpacing: 3
  });
}
function slideTitle(slide, title, sub, light) {
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  slide.addText(title, { x: 0.5, y: 0.65, w: 9, h: 0.7, fontSize: 26, bold: true, color: fg, fontFace: "Calibri" });
  if (sub) {
    slide.addText(sub, { x: 0.5, y: 1.3, w: 9, h: 0.35, fontSize: 13, color: light ? C.teal : C.skyBlue, fontFace: "Calibri", italic: true });
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}
function accentBar(slide, x, y, h, color) {
  slide.addShape(pres.ShapeType.rect, { x, y, w: 0.07, h, fill: { color: color || C.amber } });
}
function footer(slide, text) {
  slide.addText(text || "Priapism — Clinical Review", {
    x: 0, y: 5.3, w: 10, h: 0.32, fontSize: 8, color: "AAAAAA", align: "center"
  });
}

// ─── Fetch images ─────────────────────────────────────────────────
const imgUrls = [
  "https://cdn.orris.care/cdss_images/8e9973b1867bd6ec17b0b5162757489d46fc2578c48adac73e2296cc045e19f7.png",
  "https://cdn.orris.care/cdss_images/1ca6c52f05ff90beda5062544aea5866817fc238dfacfad85deb247c142fe38f.png"
];
let imgs = [];
try {
  const raw = execSync(`node /home/daytona/skills/shared/scripts/fetch_images.js "${imgUrls[0]}" "${imgUrls[1]}"`, { timeout: 30000 }).toString();
  imgs = JSON.parse(raw);
} catch(e) {
  console.log("Image fetch failed:", e.message);
}


// ═══════════════════════════════════════════════════════════════════
// SLIDE 1 — TITLE SLIDE
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);

  // Left accent stripe
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.45, h: 5.625, fill: { color: C.teal } });
  s.addShape(pres.ShapeType.rect, { x: 0.45, y: 0, w: 0.1, h: 5.625, fill: { color: C.amber } });

  // Main title
  s.addText("PRIAPISM", {
    x: 0.75, y: 1.0, w: 8.5, h: 1.3, fontSize: 64, bold: true,
    color: C.white, fontFace: "Calibri", charSpacing: 8
  });
  s.addText("Comprehensive Clinical Review", {
    x: 0.75, y: 2.25, w: 8.5, h: 0.6, fontSize: 24, color: C.skyBlue,
    fontFace: "Calibri", italic: true
  });

  // Horizontal rule
  s.addShape(pres.ShapeType.rect, { x: 0.75, y: 2.95, w: 6, h: 0.04, fill: { color: C.amber } });

  // Topics line
  s.addText("Definition  •  Classification  •  Pathophysiology  •  Diagnosis  •  Management  •  Complications", {
    x: 0.75, y: 3.15, w: 9, h: 0.4, fontSize: 11, color: "99BBD0", fontFace: "Calibri"
  });

  // Source note
  s.addText("Sources: Campbell-Walsh Urology • Smith & Tanagho General Urology • Goldman-Cecil Medicine • Bailey & Love Surgery", {
    x: 0.75, y: 5.0, w: 9, h: 0.3, fontSize: 8, color: "667788", fontFace: "Calibri"
  });
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 2 — DEFINITION & OVERVIEW
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Definition & Overview");
  slideTitle(s, "What is Priapism?", "A urologic emergency requiring prompt recognition", true);

  accentBar(s, 0.5, 1.7, 3.3, C.teal);

  const definitionText = [
    { text: "Core Definition", options: { bold: true, fontSize: 14, color: C.navy, breakLine: true } },
    { text: "Prolonged, persistent penile erection unrelated to sexual interest or stimulation, lasting longer than ", options: { fontSize: 12, color: C.midText } },
    { text: "4 hours", options: { bold: true, fontSize: 12, color: C.red } },
    { text: ".", options: { fontSize: 12, color: C.midText, breakLine: true } },
    { text: " ", options: { fontSize: 8, breakLine: true } },
    { text: "Key Features", options: { bold: true, fontSize: 14, color: C.navy, breakLine: true } },
    { text: "• Tumescence confined to corpora cavernosa (corpus spongiosum usually spared)", options: { fontSize: 12, color: C.midText, bullet: false, breakLine: true } },
    { text: "• Glans and corpus spongiosum are typically soft", options: { fontSize: 12, color: C.midText, breakLine: true } },
    { text: "• Considered one of the most common urologic emergencies", options: { fontSize: 12, color: C.midText, breakLine: true } },
    { text: "• Incidence: up to 5.34 per 100,000 men per year (ischemic type)", options: { fontSize: 12, color: C.midText, breakLine: true } },
  ];
  s.addText(definitionText, { x: 0.65, y: 1.7, w: 5.8, h: 3.3, valign: "top", margin: 8 });

  // Info box right
  s.addShape(pres.ShapeType.roundRect, { x: 6.8, y: 1.65, w: 2.9, h: 1.5, fill: { color: C.navy }, rectRadius: 0.1 });
  s.addText([
    { text: "Duration Threshold", options: { bold: true, fontSize: 13, color: C.amber, breakLine: true } },
    { text: "> 4 hours", options: { fontSize: 28, bold: true, color: C.white, breakLine: true } },
    { text: "requires emergency evaluation", options: { fontSize: 11, color: C.skyBlue } },
  ], { x: 6.9, y: 1.7, w: 2.7, h: 1.4, align: "center", valign: "middle" });

  s.addShape(pres.ShapeType.roundRect, { x: 6.8, y: 3.3, w: 2.9, h: 1.7, fill: { color: C.teal }, rectRadius: 0.1 });
  s.addText([
    { text: "Most Affected", options: { bold: true, fontSize: 13, color: C.white, breakLine: true } },
    { text: "• Sickle cell disease patients\n• 2–29% lifetime risk in SCD\n• Also idiopathic (60% of cases)", options: { fontSize: 11, color: C.offWhite } },
  ], { x: 6.9, y: 3.35, w: 2.7, h: 1.6, valign: "top", margin: 6 });

  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 3 — CLASSIFICATION
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Classification", C.navy);
  slideTitle(s, "Three Types of Priapism", "Ischemic • Non-ischemic • Stuttering", true);

  // TYPE 1 — Ischemic
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.55, w: 2.9, h: 3.6, fill: { color: C.red }, rectRadius: 0.12 });
  s.addText([
    { text: "01", options: { fontSize: 36, bold: true, color: "FFAAAA", breakLine: true } },
    { text: "ISCHEMIC", options: { fontSize: 16, bold: true, color: C.white, breakLine: true, charSpacing: 2 } },
    { text: "Low-flow / Veno-occlusive", options: { fontSize: 10, color: "FFCCCC", italic: true, breakLine: true } },
    { text: " ", options: { fontSize: 7, breakLine: true } },
    { text: "• Most common type\n• Venous outflow obstruction\n• NO cavernous blood flow\n• Rigid & tender corpora\n• Hypoxic, hypercapnic, acidotic blood gas\n• MEDICAL EMERGENCY", options: { fontSize: 10, color: C.white } },
  ], { x: 0.4, y: 1.65, w: 2.7, h: 3.4, valign: "top", margin: 8 });

  // TYPE 2 — Non-ischemic
  s.addShape(pres.ShapeType.roundRect, { x: 3.55, y: 1.55, w: 2.9, h: 3.6, fill: { color: C.green }, rectRadius: 0.12 });
  s.addText([
    { text: "02", options: { fontSize: 36, bold: true, color: "AAFFCC", breakLine: true } },
    { text: "NON-ISCHEMIC", options: { fontSize: 14, bold: true, color: C.white, breakLine: true, charSpacing: 2 } },
    { text: "High-flow / Arterial", options: { fontSize: 10, color: "CCFFEE", italic: true, breakLine: true } },
    { text: " ", options: { fontSize: 7, breakLine: true } },
    { text: "• Less common\n• Unregulated cavernous arterial inflow\n• Usually from perineal/penile trauma\n• Cavernosal artery fistula\n• NOT fully rigid; painless\n• NOT a medical emergency\n• High O2, normal CO2 on blood gas", options: { fontSize: 10, color: C.white } },
  ], { x: 3.65, y: 1.65, w: 2.7, h: 3.4, valign: "top", margin: 8 });

  // TYPE 3 — Stuttering
  s.addShape(pres.ShapeType.roundRect, { x: 6.8, y: 1.55, w: 2.9, h: 3.6, fill: { color: C.teal }, rectRadius: 0.12 });
  s.addText([
    { text: "03", options: { fontSize: 36, bold: true, color: "AADDEE", breakLine: true } },
    { text: "STUTTERING", options: { fontSize: 15, bold: true, color: C.white, breakLine: true, charSpacing: 2 } },
    { text: "Recurrent / Intermittent", options: { fontSize: 10, color: "CCEEEE", italic: true, breakLine: true } },
    { text: " ", options: { fontSize: 7, breakLine: true } },
    { text: "• Recurrent form of ischemic priapism\n• Periodic painful erections\n• Shorter duration with detumescence intervals\n• Common in sickle cell disease\n• PDE5 dysregulation implicated\n• Abnormal NO/cGMP signaling", options: { fontSize: 10, color: C.white } },
  ], { x: 6.9, y: 1.65, w: 2.7, h: 3.4, valign: "top", margin: 8 });

  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 4 — ETIOLOGY & RISK FACTORS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Etiology & Risk Factors", C.teal);
  slideTitle(s, "Causes of Priapism", "Idiopathic in ~60% of cases", true);

  // Left column
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.6, w: 4.5, h: 3.7, fill: { color: C.navy }, rectRadius: 0.1 });
  s.addText([
    { text: "Hematologic / Systemic", options: { bold: true, fontSize: 13, color: C.amber, breakLine: true } },
    { text: "• Sickle cell disease (most common identifiable cause)\n• Leukemia & other hematologic malignancies\n• Other hemoglobinopathies\n• G6PD deficiency\n• Thalassemia", options: { fontSize: 11, color: C.white } },
    { text: "\nMedications & Substances", options: { bold: true, fontSize: 13, color: C.skyBlue, breakLine: true } },
    { text: "• Intracavernous injection therapy (most common iatrogenic cause)\n• Trazodone (antidepressant)\n• Antipsychotics (clozapine, chlorpromazine)\n• Alcohol & recreational drugs\n• Anticoagulants", options: { fontSize: 11, color: C.white } },
  ], { x: 0.45, y: 1.7, w: 4.2, h: 3.5, valign: "top", margin: 8 });

  // Right column
  s.addShape(pres.ShapeType.roundRect, { x: 5.1, y: 1.6, w: 4.5, h: 3.7, fill: { color: C.lightGray }, rectRadius: 0.1 });
  s.addText([
    { text: "Neurologic", options: { bold: true, fontSize: 13, color: C.navy, breakLine: true } },
    { text: "• Spinal cord injury / trauma\n• Cauda equina syndrome", options: { fontSize: 11, color: C.midText } },
    { text: "\nNeoplastic", options: { bold: true, fontSize: 13, color: C.navy, breakLine: true } },
    { text: "• Pelvic tumors with local invasion\n• Penile metastasis", options: { fontSize: 11, color: C.midText } },
    { text: "\nTraumatic (Non-ischemic)", options: { bold: true, fontSize: 13, color: C.navy, breakLine: true } },
    { text: "• Perineal or penile blunt trauma\n• Cavernosal artery injury → AV fistula", options: { fontSize: 11, color: C.midText } },
    { text: "\nIdiopathic", options: { bold: true, fontSize: 13, color: C.navy, breakLine: true } },
    { text: "• ~60% of all cases — no identifiable cause\n• Often preceded by prolonged sexual stimulation", options: { fontSize: 11, color: C.midText } },
  ], { x: 5.25, y: 1.7, w: 4.2, h: 3.5, valign: "top", margin: 8 });

  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 5 — PATHOPHYSIOLOGY
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  sectionBand(s, "Pathophysiology", C.teal);
  slideTitle(s, "Mechanisms of Priapism", "Ischemic vs Non-Ischemic Pathways");

  // Ischemic pathway box
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.55, w: 4.4, h: 3.8, fill: { color: "1A0505" }, rectRadius: 0.1 });
  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.55, w: 4.4, h: 0.4, fill: { color: C.red } });
  s.addText("ISCHEMIC (Low-Flow)", { x: 0.4, y: 1.55, w: 4.2, h: 0.4, fontSize: 12, bold: true, color: C.white, valign: "middle", margin: 0 });

  const ischemicSteps = [
    "1. Venous outflow obstruction from corpora cavernosa",
    "2. Reduced arterial inflow → blood stasis",
    "3. Falling O2 tension + rising CO2 + acidosis",
    "4. Sickling of RBCs worsens stasis (in SCD)",
    "5. Endothelial & smooth muscle damage",
    "6. PDE5 dysregulation + NO/cGMP dysfunction",
    "7. Interstitial edema → fibrosis if untreated",
    "8. Impotence (most common long-term sequela)",
  ];
  s.addText(ischemicSteps.map((t, i) => ({
    text: t + (i < ischemicSteps.length - 1 ? "\n" : ""),
    options: { fontSize: 10, color: i === 7 ? C.amber : "FFDDDD", bullet: false }
  })).flat(), { x: 0.4, y: 2.05, w: 4.1, h: 3.2, valign: "top", margin: 6 });

  // Non-ischemic pathway
  s.addShape(pres.ShapeType.roundRect, { x: 5.0, y: 1.55, w: 4.6, h: 3.8, fill: { color: "01180E" }, rectRadius: 0.1 });
  s.addShape(pres.ShapeType.rect, { x: 5.0, y: 1.55, w: 4.6, h: 0.4, fill: { color: C.green } });
  s.addText("NON-ISCHEMIC (High-Flow)", { x: 5.1, y: 1.55, w: 4.4, h: 0.4, fontSize: 12, bold: true, color: C.white, valign: "middle", margin: 0 });

  const nonIschemicSteps = [
    "1. Perineal or penile trauma (blunt injury)",
    "2. Cavernosal / helicine artery disruption",
    "3. AV fistula formation between artery & sinusoids",
    "4. Unregulated arterial inflow",
    "5. Venous drainage preserved → no ischemia",
    "6. Persistent painless tumescence",
    "7. High O2 / normal CO2 on corporal blood gas",
    "8. Erectile function often preserved",
  ];
  s.addText(nonIschemicSteps.map((t, i) => ({
    text: t + (i < nonIschemicSteps.length - 1 ? "\n" : ""),
    options: { fontSize: 10, color: i === 7 ? C.amber : "CCFFEE", bullet: false }
  })).flat(), { x: 5.1, y: 2.05, w: 4.3, h: 3.2, valign: "top", margin: 6 });

  footer(s, "Priapism — Pathophysiology");
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 6 — DIAGNOSIS / EVALUATION
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Diagnosis & Evaluation", C.navy);
  slideTitle(s, "Clinical Evaluation", "History, Examination & Investigations", true);

  // History box
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.6, w: 3.0, h: 3.7, fill: { color: C.navy }, rectRadius: 0.1 });
  s.addText([
    { text: "History", options: { bold: true, fontSize: 13, color: C.amber, breakLine: true } },
    { text: "• Duration of erection\n• Sexual stimulation (absent)\n• Pain character\n• Prior episodes\n• Medications (trazodone, intracavernous agents, antipsychotics)\n• Sickle cell disease Hx\n• Trauma (perineal/penile)\n• Recreational drug use", options: { fontSize: 10.5, color: C.white } },
  ], { x: 0.4, y: 1.7, w: 2.8, h: 3.5, valign: "top", margin: 6 });

  // PE box
  s.addShape(pres.ShapeType.roundRect, { x: 3.5, y: 1.6, w: 3.0, h: 3.7, fill: { color: C.teal }, rectRadius: 0.1 });
  s.addText([
    { text: "Physical Exam", options: { bold: true, fontSize: 13, color: C.white, breakLine: true } },
    { text: "• Rigid, tender corpora cavernosa (ischemic)\n• Soft corpus spongiosum & glans\n• Semi-rigid, painless penis (non-ischemic)\n• Signs of perineal trauma\n• Lymphadenopathy (malignancy)\n• Signs of SCD crisis", options: { fontSize: 10.5, color: C.offWhite } },
    { text: "\nBlood Gas Key Findings", options: { bold: true, fontSize: 12, color: C.amber, breakLine: true } },
    { text: "Ischemic: pO2 <30, pCO2 >60, pH <7.25\nNon-ischemic: pO2 >90, pCO2 normal, pH normal", options: { fontSize: 10, color: C.white } },
  ], { x: 3.6, y: 1.7, w: 2.8, h: 3.5, valign: "top", margin: 6 });

  // Investigations box
  s.addShape(pres.ShapeType.roundRect, { x: 6.7, y: 1.6, w: 3.0, h: 3.7, fill: { color: C.lightGray }, rectRadius: 0.1 });
  s.addText([
    { text: "Investigations", options: { bold: true, fontSize: 13, color: C.navy, breakLine: true } },
    { text: "1st Line", options: { bold: true, fontSize: 11, color: C.teal, breakLine: true } },
    { text: "• Corporal blood gas aspiration (21G butterfly needle)\n• CBC, coagulation screen\n• Toxicology screen\n• Hemoglobin electrophoresis (if SCD suspected)", options: { fontSize: 10, color: C.midText } },
    { text: "\n2nd Line", options: { bold: true, fontSize: 11, color: C.teal, breakLine: true } },
    { text: "• Color Doppler ultrasound (if available) — differentiates high vs low flow\n• Pelvic angiography (non-ischemic — identifies fistula for embolization)\n• MRI (rarely needed)", options: { fontSize: 10, color: C.midText } },
  ], { x: 6.8, y: 1.7, w: 2.8, h: 3.5, valign: "top", margin: 6 });

  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 7 — BLOOD GAS COMPARISON TABLE
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Differentiation", C.red);
  slideTitle(s, "Ischemic vs Non-Ischemic: Key Differences", "", true);

  const rows = [
    [
      { text: "Feature", options: { bold: true, color: C.white, fontSize: 12 } },
      { text: "Ischemic (Low-Flow)", options: { bold: true, color: C.white, fontSize: 12 } },
      { text: "Non-Ischemic (High-Flow)", options: { bold: true, color: C.white, fontSize: 12 } },
      { text: "Stuttering", options: { bold: true, color: C.white, fontSize: 12 } },
    ],
    ["Mechanism", "Venous outflow obstruction", "Unregulated arterial inflow (AV fistula)", "Recurrent ischemic episodes"],
    ["Cause", "SCD, idiopathic, drugs", "Perineal/penile trauma", "SCD (most common)"],
    ["Pain", "Yes — painful", "No — painless", "Yes — intermittent pain"],
    ["Rigidity", "Rigid corpora", "Semi-rigid / tumescent", "Variable"],
    ["Blood O2", "Low (<30 mmHg)", "Normal / High (>90 mmHg)", "Low during episodes"],
    ["Blood CO2", "High (>60 mmHg)", "Normal", "High during episodes"],
    ["Blood pH", "<7.25 (acidotic)", "Normal (7.35–7.45)", "Acidotic during episodes"],
    ["Emergency?", "YES — urologic emergency", "No — not an emergency", "Yes — treat each episode"],
    ["Doppler Flow", "Absent / low", "Turbulent high flow", "Absent during episode"],
    ["Treatment", "Aspiration + phenylephrine → shunt", "Conservative → angioembolization", "Symptomatic + preventive"],
  ];

  s.addTable(rows, {
    x: 0.3, y: 1.5, w: 9.4, h: 3.9,
    border: { type: "solid", color: "CCDDEE", pt: 0.5 },
    fill: { color: C.offWhite },
    rowH: 0.33,
    fontFace: "Calibri",
    fontSize: 10,
    color: C.darkText,
    colW: [1.6, 2.3, 2.5, 2.0],
    autoPage: false,
  });

  // override header row color via fill
  // (pptxgenjs colors the first row when you set header options)
  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 8 — MANAGEMENT ALGORITHM (with textbook image)
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Management", C.teal);
  slideTitle(s, "Management of Ischemic Priapism", "Time-dependent treatment algorithm", true);

  // Show the textbook flowchart image if available
  if (imgs[0] && imgs[0].base64) {
    s.addImage({ data: imgs[0].base64, x: 0.3, y: 1.5, w: 5.2, h: 3.8 });
    s.addText("Figure: Management of Ischemic Priapism\n(Smith & Tanagho General Urology / Hudnall et al. 2017)", {
      x: 0.3, y: 5.2, w: 5.2, h: 0.3, fontSize: 7, color: "888888", italic: true
    });
  } else {
    // Fallback flowchart text
    s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.5, w: 5.2, h: 3.8, fill: { color: C.lightGray }, rectRadius: 0.1 });
    s.addText("Management Flowchart\n(see notes)", { x: 0.3, y: 2.5, w: 5.2, h: 1.5, fontSize: 14, color: C.midText, align: "center" });
  }

  // Steps panel
  s.addShape(pres.ShapeType.roundRect, { x: 5.8, y: 1.5, w: 3.9, h: 3.8, fill: { color: C.navy }, rectRadius: 0.1 });
  s.addText([
    { text: "Step-by-Step", options: { bold: true, fontSize: 13, color: C.amber, breakLine: true } },
    { text: "\n< 24 hours", options: { bold: true, fontSize: 12, color: C.skyBlue, breakLine: true } },
    { text: "• Corporal aspiration (21G butterfly)\n• Phenylephrine 500 μg q5min IC\n• Blood gas to confirm ischemic type", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\n1–2 days", options: { bold: true, fontSize: 12, color: C.skyBlue, breakLine: true } },
    { text: "• T-shunt (Ebbehoj / Winter / Al-Ghorab)\n• Perioperative anticoagulation\n(Heparin 5000 U + Aspirin 325 mg)", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\n> 2 days", options: { bold: true, fontSize: 12, color: C.amber, breakLine: true } },
    { text: "• T-shunt + Tunneling + Anticoagulation\n• Consider early penile prosthesis\n  (within 4 weeks → better outcomes)", options: { fontSize: 10, color: C.white } },
  ], { x: 5.9, y: 1.6, w: 3.6, h: 3.6, valign: "top", margin: 8 });

  footer(s, "Priapism — Ischemic Management");
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 9 — SURGICAL SHUNTS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Surgical Management", C.navy);
  slideTitle(s, "Shunt Procedures for Ischemic Priapism", "When aspiration + pharmacotherapy fail", true);

  // Distal shunts
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.55, w: 4.4, h: 1.9, fill: { color: C.navy }, rectRadius: 0.1 });
  s.addText([
    { text: "Distal Shunts (1st choice)", options: { bold: true, fontSize: 12, color: C.skyBlue, breakLine: true } },
    { text: "• Ebbehoj shunt — needle puncture of glans into corpus\n• Winter shunt — Tru-cut biopsy needle (percutaneous)\n• T-shunt — scalpel excision of tunical wedge\n• Al-Ghorab — open excision bilateral corporal windows", options: { fontSize: 10.5, color: C.white } },
  ], { x: 0.45, y: 1.65, w: 4.15, h: 1.75, valign: "top", margin: 6 });

  // Proximal shunts
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 3.6, w: 4.4, h: 1.7, fill: { color: C.teal }, rectRadius: 0.1 });
  s.addText([
    { text: "Proximal Shunts (historically used)", options: { bold: true, fontSize: 12, color: C.white, breakLine: true } },
    { text: "• Quackels (1964) — cavernosum-spongiosum anastomosis\n• Barry — cavernous to venous shunt\n• Now largely replaced by tunneling procedures (Lue, Burnett)", options: { fontSize: 10.5, color: C.offWhite } },
  ], { x: 0.45, y: 3.7, w: 4.15, h: 1.55, valign: "top", margin: 6 });

  // Anticoagulation box
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  s.addText([
    { text: "Perioperative Anticoagulation Protocol", options: { bold: true, fontSize: 12, color: C.navy, breakLine: true } },
    { text: "Critical to prevent premature shunt closure:", options: { fontSize: 10, color: C.navy, breakLine: true } },
    { text: "Preoperative: Heparin 5,000 U SQ + Aspirin 325 mg PO\nPostoperative (≥5 days): Aspirin 325 mg/day + Clopidogrel 75 mg/day", options: { fontSize: 11, bold: true, color: C.navy } },
    { text: "\n\nShunt failure occurs due to tunica albuginea incision → coagulation cascade activation", options: { fontSize: 9, color: C.midText, italic: true } },
  ], { x: 5.1, y: 1.65, w: 4.5, h: 2.15, valign: "top", margin: 8 });

  // Penile prosthesis box
  s.addShape(pres.ShapeType.roundRect, { x: 5.0, y: 4.0, w: 4.7, h: 1.3, fill: { color: C.lightGray }, rectRadius: 0.1 });
  s.addText([
    { text: "Early Penile Prosthesis Implantation", options: { bold: true, fontSize: 12, color: C.navy, breakLine: true } },
    { text: "For ischemia >48h: Early implantation (<4 weeks) → less erosion/infection, higher satisfaction, less penile shortening vs delayed implantation (Systematic Review 2024, PMID: 38465856)", options: { fontSize: 10, color: C.midText } },
  ], { x: 5.1, y: 4.1, w: 4.5, h: 1.2, valign: "top", margin: 6 });

  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 10 — NON-ISCHEMIC MANAGEMENT
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Non-Ischemic & Stuttering Management", C.green);
  slideTitle(s, "Non-Ischemic & Stuttering Priapism", "Different pathways — different treatments", true);

  // Non-ischemic left
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.55, w: 4.5, h: 3.8, fill: { color: C.green }, rectRadius: 0.1 });
  s.addText([
    { text: "Non-Ischemic Priapism", options: { bold: true, fontSize: 14, color: C.white, breakLine: true } },
    { text: "High-flow / Arterial", options: { italic: true, fontSize: 11, color: "CCFFEE", breakLine: true } },
    { text: " ", options: { fontSize: 7, breakLine: true } },
    { text: "Conservative (1st line):", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "• Observation & perineal ice packs\n• Many cases self-resolve\n• NOT a medical emergency", options: { fontSize: 10.5, color: C.white, breakLine: true } },
    { text: "\nAngiography & Embolization:", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "• Identifies cavernosal AV fistula\n• Superselective embolization\n• Preserves erectile function\n• Autologous clot or absorbable materials preferred (reversible)", options: { fontSize: 10.5, color: C.white } },
  ], { x: 0.45, y: 1.65, w: 4.2, h: 3.6, valign: "top", margin: 8 });

  // Stuttering right
  s.addShape(pres.ShapeType.roundRect, { x: 5.1, y: 1.55, w: 4.5, h: 3.8, fill: { color: C.navy }, rectRadius: 0.1 });
  s.addText([
    { text: "Stuttering Priapism", options: { bold: true, fontSize: 14, color: C.skyBlue, breakLine: true } },
    { text: "Recurrent Ischemic", options: { italic: true, fontSize: 11, color: "88CCDD", breakLine: true } },
    { text: " ", options: { fontSize: 7, breakLine: true } },
    { text: "Acute episode:", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "• Home self-injection protocol\n• Oral α-adrenergic agents at onset\n• Pseudoephedrine at bedtime\n• Emergency aspiration if >4 hours", options: { fontSize: 10.5, color: C.white, breakLine: true } },
    { text: "\nPrevention / Long-term:", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "• PDE5 inhibitors (paradoxically preventive — normalize PDE5 regulation)\n• Oral β-agonists\n• Antiandrogens (reduce nocturnal erections)\n• GnRH analogues (for refractory cases)\n• Hydroxyurea (for SCD-related stuttering)", options: { fontSize: 10.5, color: C.white } },
  ], { x: 5.25, y: 1.65, w: 4.2, h: 3.6, valign: "top", margin: 8 });

  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 11 — SICKLE CELL DISEASE SPECIAL CONSIDERATIONS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Special Populations", C.red);
  slideTitle(s, "Priapism in Sickle Cell Disease", "Most common identifiable cause — 2–29% lifetime risk", true);

  // Left info
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.55, w: 5.5, h: 3.8, fill: { color: C.navy }, rectRadius: 0.1 });
  s.addText([
    { text: "Pathomechanism in SCD", options: { bold: true, fontSize: 12, color: C.amber, breakLine: true } },
    { text: "• HbS-predominant RBCs sickle within corpora cavernosa sinusoids during normal erection\n• Causes venous stasis → decreased pH + local O2 tension\n• Potentiates further sickling — a vicious cycle\n• Most episodes occur during sleep\n  (mild hypoventilatory acidosis + oxyhemoglobin desaturation)\n• Pain = sign of tissue ischemia", options: { fontSize: 10.5, color: C.white, breakLine: true } },
    { text: "\nManagement Priority", options: { bold: true, fontSize: 12, color: C.skyBlue, breakLine: true } },
    { text: "• Initial conservative: Hydration + Oxygenation + Alkalization + Analgesia\n• Exchange transfusion (reduces HbS concentration)\n• Evacuation + IC α-adrenergic injection (phenylephrine)\n• Surgical shunting if medical Rx fails\n• Educate patients: seek ED for episodes >1 hour", options: { fontSize: 10.5, color: C.white } },
  ], { x: 0.45, y: 1.65, w: 5.25, h: 3.6, valign: "top", margin: 8 });

  // Right stats / pearls
  s.addShape(pres.ShapeType.roundRect, { x: 6.1, y: 1.55, w: 3.6, h: 1.7, fill: { color: C.red }, rectRadius: 0.1 });
  s.addText([
    { text: "Lifetime Risk in SCD", options: { bold: true, fontSize: 12, color: C.white, breakLine: true } },
    { text: "2–29%", options: { fontSize: 36, bold: true, color: C.white, breakLine: true } },
    { text: "Males with homozygous HbSS", options: { fontSize: 10, color: "FFCCCC" } },
  ], { x: 6.15, y: 1.6, w: 3.45, h: 1.6, align: "center", valign: "middle" });

  s.addShape(pres.ShapeType.roundRect, { x: 6.1, y: 3.4, w: 3.6, h: 2.0, fill: { color: C.lightGray }, rectRadius: 0.1 });
  s.addText([
    { text: "Pediatric SCD Pearls", options: { bold: true, fontSize: 12, color: C.navy, breakLine: true } },
    { text: "• Stuttering priapism more common than fulminant in children\n• Pseudoephedrine at bedtime (oral α-agonist)\n• PDE5 inhibitors may prevent recurrence\n• Treat same as adults — accommodated guidelines (AUA/EAU)", options: { fontSize: 10, color: C.midText } },
  ], { x: 6.15, y: 3.5, w: 3.45, h: 1.8, valign: "top", margin: 6 });

  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 12 — COMPLICATIONS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  sectionBand(s, "Complications & Outcomes", C.red);
  slideTitle(s, "Complications of Priapism", "Impotence is the most feared long-term sequel");

  // Big stat
  s.addShape(pres.ShapeType.roundRect, { x: 0.3, y: 1.55, w: 2.8, h: 3.8, fill: { color: C.red }, rectRadius: 0.1 });
  s.addText([
    { text: "Erectile\nDysfunction", options: { fontSize: 16, bold: true, color: C.white, breakLine: true } },
    { text: "#1 Complication", options: { fontSize: 11, color: "FFAAAA", italic: true, breakLine: true } },
    { text: " ", options: { fontSize: 10, breakLine: true } },
    { text: "Worse with:", options: { fontSize: 11, color: C.amber, bold: true, breakLine: true } },
    { text: "• Prolonged ischemia (>24h)\n• Delayed treatment\n• Repeated episodes\n• Fibrosis of corpora", options: { fontSize: 11, color: C.white } },
  ], { x: 0.45, y: 1.65, w: 2.55, h: 3.6, valign: "top", margin: 8 });

  // Complication list
  s.addShape(pres.ShapeType.roundRect, { x: 3.3, y: 1.55, w: 3.3, h: 3.8, fill: { color: "0A1E30" }, rectRadius: 0.1 });
  s.addText([
    { text: "Other Complications", options: { bold: true, fontSize: 13, color: C.skyBlue, breakLine: true } },
    { text: " ", options: { fontSize: 7, breakLine: true } },
    { text: "Penile fibrosis", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "From smooth muscle necrosis & collagen deposition", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\nPenile shortening", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "Post-ischemia corporal scarring", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\nShunt failure", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "Clot formation over tunica incision", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\nInfection / erosion", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "Post-prosthesis (less with early implant)", options: { fontSize: 10, color: C.white } },
  ], { x: 3.45, y: 1.65, w: 3.05, h: 3.6, valign: "top", margin: 8 });

  // Timeline
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  s.addText([
    { text: "Time & Outcome", options: { bold: true, fontSize: 13, color: C.white, breakLine: true } },
    { text: " ", options: { fontSize: 7, breakLine: true } },
    { text: "< 4 hours", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "Excellent prognosis for erectile function", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\n4–24 hours", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "Good if treated promptly", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\n24–48 hours", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "Moderate risk of ED", options: { fontSize: 10, color: C.white, breakLine: true } },
    { text: "\n> 48 hours", options: { bold: true, fontSize: 11, color: C.amber, breakLine: true } },
    { text: "High risk of permanent ED; consider early prosthesis", options: { fontSize: 10, color: C.white } },
  ], { x: 6.9, y: 1.65, w: 2.65, h: 3.6, valign: "top", margin: 8 });

  footer(s, "Priapism — Complications & Outcomes");
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 13 — KEY DRUGS & DOSES
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  lightSlide(s);
  sectionBand(s, "Pharmacotherapy", C.teal);
  slideTitle(s, "Drug Therapy Summary", "Agents used in acute and preventive management", true);

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    [
      { text: "Drug", options: { bold: true, color: C.white, fontSize: 11 } },
      { text: "Class", options: { bold: true, color: C.white, fontSize: 11 } },
      { text: "Dose / Route", options: { bold: true, color: C.white, fontSize: 11 } },
      { text: "Indication", options: { bold: true, color: C.white, fontSize: 11 } },
      { text: "Notes", options: { bold: true, color: C.white, fontSize: 11 } },
    ],
    ["Phenylephrine", "α1-agonist", "500 μg IC q5min", "Ischemic priapism (1st line)", "Preferred — minimal CV risk"],
    ["Epinephrine", "α+β agonist", "Dilute IC injection", "Ischemic priapism", "Use with caution (CV effects)"],
    ["Pseudoephedrine", "Oral α-agonist", "30–60 mg PO at bedtime", "Stuttering priapism prevention", "Especially in children with SCD"],
    ["Terbutaline", "β2-agonist", "0.25–0.5 mg SC / PO", "Stuttering / early ischemic", "Less effective than phenylephrine"],
    ["PDE5 Inhibitors", "PDE5 inhibitor", "Daily low-dose PO", "Prevent recurrent stuttering", "Paradoxically preventive via PDE5 normalization"],
    ["Heparin", "Anticoagulant", "5,000 U SQ periop", "Post-shunt anticoagulation", "Prevents premature shunt closure"],
    ["Aspirin", "Antiplatelet", "325 mg PO periop → 5 days", "Post-shunt anticoagulation", "Combined with clopidogrel postop"],
    ["Clopidogrel", "Antiplatelet (P2Y12)", "75 mg PO daily × 5 days", "Post-shunt (postoperative)", "With aspirin after shunt procedure"],
    ["Hydroxyurea", "Cytoreductive agent", "Per SCD protocol", "SCD-related stuttering (long-term)", "Disease-modifying in SCD"],
    ["Antiandrogens / GnRH", "Hormonal", "Various regimens", "Refractory stuttering priapism", "Reduce nocturnal erections"],
  ];

  s.addTable(drugRows, {
    x: 0.3, y: 1.5, w: 9.4, h: 3.9,
    border: { type: "solid", color: "CCDDEE", pt: 0.5 },
    fill: { color: C.white },
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    fontSize: 9.5,
    color: C.darkText,
    colW: [1.6, 1.4, 1.9, 2.2, 2.3],
    autoPage: false,
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  footer(s);
}

// ═══════════════════════════════════════════════════════════════════
// SLIDE 14 — SUMMARY & KEY POINTS
// ═══════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  darkSlide(s);
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 5.625, fill: { color: C.navy } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 0.45, h: 5.625, fill: { color: C.teal } });
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    x: 0.75, y: 0.3, w: 9, h: 0.7, fontSize: 32, bold: true, color: C.white, charSpacing: 8
  });
  s.addShape(pres.ShapeType.rect, { x: 0.75, y: 0.98, w: 5, h: 0.04, fill: { color: C.amber } });

  s.addText([
    { text: "1. ", options: { bold: true, color: C.amber } },
    { text: "Priapism = erection >4 hours unrelated to stimulation — ", options: { color: C.white } },
    { text: "Ischemic is the urologic emergency.", options: { bold: true, color: C.red, breakLine: true } },

    { text: "2. ", options: { bold: true, color: C.amber } },
    { text: "Three types: Ischemic (low-flow, painful, rigid), Non-ischemic (high-flow, painless, post-trauma), Stuttering (recurrent ischemic).", options: { color: C.white, breakLine: true } },

    { text: "3. ", options: { bold: true, color: C.amber } },
    { text: "Sickle cell disease is the most common identifiable cause — affects 2–29% of males with HbSS.", options: { color: C.white, breakLine: true } },

    { text: "4. ", options: { bold: true, color: C.amber } },
    { text: "Diagnosis: Corporal blood gas — hypoxic/hypercapnic/acidotic = ischemic; normal gases = non-ischemic. Doppler USS confirms.", options: { color: C.white, breakLine: true } },

    { text: "5. ", options: { bold: true, color: C.amber } },
    { text: "Treatment of ischemic: Aspiration + Phenylephrine → Surgical shunt (distal first) → Tunneling → Early prosthesis if >48 hours.", options: { color: C.white, breakLine: true } },

    { text: "6. ", options: { bold: true, color: C.amber } },
    { text: "Perioperative anticoagulation (Heparin + Aspirin ± Clopidogrel) prevents shunt failure.", options: { color: C.white, breakLine: true } },

    { text: "7. ", options: { bold: true, color: C.amber } },
    { text: "Non-ischemic: Not an emergency — conservative first; angioembolization for persistent cases.", options: { color: C.white, breakLine: true } },

    { text: "8. ", options: { bold: true, color: C.amber } },
    { text: "Impotence is the #1 sequela — early diagnosis and treatment (<4 hours) offers best prognosis.", options: { color: C.white } },
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// ─── WRITE FILE ───────────────────────────────────────────────────
const outPath = "/home/daytona/workspace/priapism-ppt/Priapism_Comprehensive.pptx";
pres.writeFile({ fileName: outPath })
  .then(() => console.log("SUCCESS: " + outPath))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });