scabies children treatment

mkdir -p /home/daytona/workspace/scabies-cme && ls /home/daytona/workspace/scabi…

~/scabies-cme/build.js

const pptxgen = require("pptxgenjs");

const pres = new pptxgen();
pres.layout = "LAYOUT_16x9";
pres.author = "CME Faculty";
pres.title = "Scabies in Pediatric Practice – CME";

// ─── PALETTE ─────────────────────────────────────────────────────────────────
const TEAL_DARK  = "004D5B";   // dominant – titles, header bars
const TEAL_MID   = "007A91";   // accent blocks
const TEAL_LIGHT = "E0F4F7";   // slide backgrounds for content slides
const WHITE      = "FFFFFF";
const SLATE      = "2D3748";   // body text
const AMBER      = "E6A817";   // highlight / call-out accent
const RED_WARN   = "C0392B";   // warning text
const GRAY_RULE  = "B0BEC5";

// ─── HELPERS ─────────────────────────────────────────────────────────────────
function addHeaderBar(slide, title, subtitle) {
  // Teal header band
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 0, w: 10, h: 1.05, fill: { color: TEAL_DARK } });
  slide.addText(title, {
    x: 0.35, y: 0.08, w: 9.3, h: 0.55,
    fontSize: 22, bold: true, color: WHITE, fontFace: "Calibri", margin: 0
  });
  if (subtitle) {
    slide.addText(subtitle, {
      x: 0.35, y: 0.62, w: 9.3, h: 0.35,
      fontSize: 12, color: "C8E6EF", fontFace: "Calibri", italic: true, margin: 0
    });
  }
  // thin amber rule under header
  slide.addShape(pres.ShapeType.rect, { x: 0, y: 1.05, w: 10, h: 0.04, fill: { color: AMBER } });
}

function bulletSlide(title, subtitle, bullets, opts = {}) {
  const slide = pres.addSlide();
  slide.background = { color: TEAL_LIGHT };
  addHeaderBar(slide, title, subtitle);
  const items = bullets.map((b, i) => {
    if (b.startsWith("  •")) {
      return { text: b.replace("  •", "").trim(), options: { bullet: { indent: 30 }, fontSize: 15, color: SLATE, breakLine: i < bullets.length - 1 } };
    }
    return { text: b, options: { bullet: { code: "25A0" }, fontSize: 16, color: SLATE, bold: b.startsWith("★"), breakLine: i < bullets.length - 1 } };
  });
  slide.addText(items, {
    x: 0.4, y: 1.2, w: 9.2, h: 4.15,
    fontFace: "Calibri", valign: "top"
  });
  if (opts.source) {
    slide.addText(opts.source, { x: 0.4, y: 5.25, w: 9.2, h: 0.28, fontSize: 9, color: GRAY_RULE, italic: true, fontFace: "Calibri" });
  }
  return slide;
}

function twoColSlide(title, subtitle, leftTitle, leftBullets, rightTitle, rightBullets, opts = {}) {
  const slide = pres.addSlide();
  slide.background = { color: TEAL_LIGHT };
  addHeaderBar(slide, title, subtitle);
  // Column boxes
  slide.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.18, w: 4.45, h: 4.15, fill: { color: WHITE }, line: { color: TEAL_MID, width: 1 } });
  slide.addShape(pres.ShapeType.rect, { x: 5.25, y: 1.18, w: 4.45, h: 4.15, fill: { color: WHITE }, line: { color: TEAL_MID, width: 1 } });
  slide.addText(leftTitle, { x: 0.3, y: 1.18, w: 4.45, h: 0.4, fontSize: 13, bold: true, color: WHITE, fill: { color: TEAL_MID }, align: "center", fontFace: "Calibri", margin: 0 });
  slide.addText(rightTitle, { x: 5.25, y: 1.18, w: 4.45, h: 0.4, fontSize: 13, bold: true, color: WHITE, fill: { color: TEAL_MID }, align: "center", fontFace: "Calibri", margin: 0 });
  const mkItems = (arr) => arr.map((b, i) => ({ text: b, options: { bullet: true, fontSize: 14, color: SLATE, breakLine: i < arr.length - 1 } }));
  slide.addText(mkItems(leftBullets), { x: 0.4, y: 1.65, w: 4.25, h: 3.6, fontFace: "Calibri", valign: "top" });
  slide.addText(mkItems(rightBullets), { x: 5.35, y: 1.65, w: 4.25, h: 3.6, fontFace: "Calibri", valign: "top" });
  if (opts.source) {
    slide.addText(opts.source, { x: 0.4, y: 5.42, w: 9.2, h: 0.18, fontSize: 9, color: GRAY_RULE, italic: true });
  }
  return slide;
}

// ─── SLIDE 1: TITLE ──────────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_DARK };
  // decorative bar
  s.addShape(pres.ShapeType.rect, { x: 0, y: 4.7, w: 10, h: 0.12, fill: { color: AMBER } });
  s.addShape(pres.ShapeType.rect, { x: 0, y: 4.82, w: 10, h: 0.8, fill: { color: "003340" } });
  s.addText("SCABIES IN PEDIATRIC PRACTICE", {
    x: 0.5, y: 0.7, w: 9, h: 1.1,
    fontSize: 38, bold: true, color: WHITE, fontFace: "Calibri",
    align: "center", charSpacing: 2
  });
  s.addText("A Continuing Medical Education Module", {
    x: 0.5, y: 1.85, w: 9, h: 0.5,
    fontSize: 20, color: "A8D8E0", fontFace: "Calibri", align: "center", italic: true
  });
  s.addText("Target Audience: Pediatricians  |  July 2026", {
    x: 0.5, y: 2.5, w: 9, h: 0.4,
    fontSize: 14, color: AMBER, fontFace: "Calibri", align: "center"
  });
  s.addText([
    { text: "Learning Objectives:", options: { bold: true, breakLine: true, color: WHITE } },
    { text: "1. Recognize classic and atypical scabies presentations in children", options: { breakLine: true, color: "C8E6EF" } },
    { text: "2. Apply evidence-based treatment strategies including age-specific dosing", options: { breakLine: true, color: "C8E6EF" } },
    { text: "3. Implement effective contact tracing and environmental control measures", options: { color: "C8E6EF" } }
  ], { x: 1.0, y: 3.1, w: 8, h: 1.4, fontSize: 14, fontFace: "Calibri" });
  s.addText("Sources: AAP Red Book 2021 | Rosen's Emergency Medicine | Fitzpatrick's Dermatology | PubMed 2023-2026", {
    x: 0.5, y: 4.85, w: 9, h: 0.6, fontSize: 9, color: GRAY_RULE, fontFace: "Calibri", align: "center"
  });
}

// ─── SLIDE 2: EPIDEMIOLOGY ────────────────────────────────────────────────────
bulletSlide(
  "Epidemiology & Burden of Disease",
  "Why Every Pediatrician Needs to Know This",
  [
    "Over 100 million people affected worldwide annually (endemic in many low- and middle-income countries)",
    "Affects all ages, genders, and socioeconomic backgrounds – not a marker of poor hygiene",
    "Children, especially in daycare and school settings, are at highest risk for spread",
    "Cyclical epidemics documented globally; prevalence peaks in winter months",
    "Sexually transmitted in adolescents and adults; consider in older teenagers",
    "Patients are infectious before symptoms appear (incubation 4–6 weeks on first exposure)",
    "  • Re-infection: symptoms emerge in just 1–4 days due to prior sensitization",
    "Endemic in parts of Southeast Asia, Pacific Islands, sub-Saharan Africa – travel history is relevant",
    "Scabies → secondary bacterial infection → post-streptococcal complications (GN, RHD) in children"
  ],
  { source: "Sources: AAP Red Book 2021, p.1031 | Rosen's EM, p.2411 | Schneider S et al., J Eur Acad Dermatol Venereol 2023 (PMID 37147907)" }
);

// ─── SLIDE 3: THE MITE – LIFE CYCLE ──────────────────────────────────────────
bulletSlide(
  "Sarcoptes scabiei – The Culprit",
  "Biology & Life Cycle",
  [
    "Obligate human ectoparasite – Sarcoptes scabiei var. hominis",
    "Adult female: 330–450 μm; burrows into stratum corneum within 30 min of skin contact",
    "Life cycle: egg → larva → nymph → adult (completed in ~10–14 days on host)",
    "Female lays 2–3 eggs/day; total of 40–50 eggs over her 4–6 week lifespan",
    "Classic infestation: average fewer than 20 mites per host",
    "Crusted (Norwegian) scabies: thousands to millions of mites",
    "Survival off host: mites can survive up to 3 days on fomites at room temperature",
    "  • This enables transmission via clothing, bed linens, towels",
    "Animal scabies (sarcoptic mange): causes self-limiting dermatitis in humans – does NOT replicate"
  ],
  { source: "Sources: AAP Red Book 2021, p.1031 | Rosen's EM, p.2411" }
);

// ─── SLIDE 4: TRANSMISSION ───────────────────────────────────────────────────
bulletSlide(
  "Transmission & Risk Factors in Children",
  "Who Gets It and How",
  [
    "PRIMARY route: prolonged direct skin-to-skin contact (hugging, sleeping together, co-bathing)",
    "INDIRECT route: fomites – shared clothing, towels, bedding (mite survives ≤3 days off skin)",
    "Daycare centers and schools: rapid spread in group-care settings",
    "Crusted scabies: even BRIEF contact or exposure to exfoliating skin scales = high transmission risk",
    "Healthcare workers and caregivers: occupational exposure risk – consider in nosocomial outbreaks",
    "Household contacts almost always need simultaneous treatment",
    "NOT transmitted by casual contact (handshake, toilet seats) in typical scabies",
    "Sexual transmission possible in adolescents"
  ],
  { source: "Sources: AAP Red Book 2021, p.1031 | Rosen's EM, p.2411" }
);

// ─── SLIDE 5: CLINICAL FEATURES – ADULTS vs. CHILDREN ────────────────────────
twoColSlide(
  "Clinical Presentation – Children vs. Adults",
  "Key Differences Pediatricians Must Know",
  "Adults / Older Children",
  [
    "Interdigital webs of hands",
    "Wrists, ankles, waist, groin",
    "Axillae, genitalia (penile/scrotal nodules highly suggestive)",
    "Nipples and areolae",
    "Buttocks",
    "Face and scalp typically SPARED",
    "Burrows – linear, 2–5 mm, grayish tracks"
  ],
  "Infants & Young Children",
  [
    "Face, scalp, neck INVOLVED",
    "Palms and soles (vesiculopustules common)",
    "Generalized involvement more frequent",
    "Predominant lesions: papules and vesicopustules",
    "Nodules common in axillary and groin folds",
    "May mimic eczema – look for family contacts with itch",
    "Secondary impetiginization frequent"
  ],
  { source: "Sources: AAP Red Book 2021, p.1031 | Rosen's EM, p.2411 | Family Medicine Textbook, p.946" }
);

// ─── SLIDE 6: HALLMARK SYMPTOMS ──────────────────────────────────────────────
bulletSlide(
  "Hallmark Symptoms",
  "Intense Pruritus – The Cardinal Clue",
  [
    "Pruritus: typically WORSE AT NIGHT (nocturnal pruritus is highly characteristic)",
    "Symptoms appear 4–6 weeks after FIRST exposure (hypersensitivity reaction to mite antigens)",
    "Re-infection: symptoms appear within 1–4 days",
    "Pruritus is out of proportion to visible skin findings in early infestation",
    "MULTIPLE HOUSEHOLD MEMBERS with itch simultaneously = strong diagnostic indicator",
    "Scratching leads to excoriations → secondary bacterial infection (Staph / Strep)",
    "Post-treatment: itching may persist for WEEKS to MONTHS even after successful eradication",
    "  • Due to residual mite antigens – do not misinterpret as treatment failure",
    "Key question to ask: 'Does anyone else at home or school also itch?'"
  ],
  { source: "Sources: AAP Red Book 2021, p.1031 | Rosen's EM, p.2411" }
);

// ─── SLIDE 7: LESION TYPES ────────────────────────────────────────────────────
bulletSlide(
  "Lesion Morphology",
  "What You See on the Skin",
  [
    "BURROWS – pathognomonic: linear/serpiginous, 2–15 mm, grayish, end in a dark dot (mite)",
    "  • Best found at wrist, interdigital spaces, penis in males",
    "  • The 'jet with contrail' dermoscopy sign: triangular brown mite body (head) + white tail",
    "Papules and vesiculopustules – most common in infants; on palms and soles",
    "Nodules – red-brown, 5–20 mm; axillae, groin, penis – may persist for months post-treatment",
    "Excoriations – secondary to scratching; may mask primary lesions",
    "Secondary eczematization – chronic itch → lichenification",
    "Impetiginization – yellow crusting, especially in children",
    "Tip: inspect fingernail margins – subungual skin is a common mite reservoir"
  ],
  { source: "Sources: Rosen's EM | Family Medicine Textbook | Fitzpatrick's Dermatology" }
);

// ─── SLIDE 8: CRUSTED SCABIES ─────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_LIGHT };
  addHeaderBar(s, "Crusted (Norwegian) Scabies", "High-Transmission Emergency");
  // Warning box
  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.15, w: 9.4, h: 0.55, fill: { color: RED_WARN } });
  s.addText("⚠  HIGHLY CONTAGIOUS – Thousands to Millions of Mites – Contact Precautions Immediately", {
    x: 0.3, y: 1.15, w: 9.4, h: 0.55, fontSize: 14, bold: true, color: WHITE, align: "center", fontFace: "Calibri", margin: 0
  });
  const items = [
    "Hyperkeratotic, thick scaly plaques – palms, soles, elbows, knees, trunk",
    "Nail thickening and dystrophy (subungual hyperkeratosis)",
    "Itch may be MINIMAL due to impaired immune response",
    "Risk groups in children: immunocompromised (HIV, malnutrition, malignancy), Down syndrome, neuropathy",
    "Even BRIEF contact or exposure to shed scales = transmission risk",
    "Hospital outbreaks documented – 1 case can infect dozens of healthcare workers",
    "Treatment: COMBINATION – topical permethrin 5% cream PLUS oral ivermectin (multiple doses)",
    "  • Keratolytic agents (urea, salicylic acid) to enhance penetration of topical scabicides",
    "  • Dermatology referral recommended",
    "Notify infection control if case identified in a healthcare or care facility"
  ].map((b, i, arr) => {
    const isSub = b.startsWith("  •");
    return {
      text: isSub ? b.replace("  •", "").trim() : b,
      options: { bullet: isSub ? { indent: 30 } : true, fontSize: 15, color: SLATE, bold: !isSub && b.startsWith("Treatment"), breakLine: i < arr.length - 1 }
    };
  });
  s.addText(items, { x: 0.4, y: 1.82, w: 9.2, h: 3.5, fontFace: "Calibri", valign: "top" });
  s.addText("Sources: AAP Red Book 2021, p.1032 | Rosen's EM, p.2411 | Bergamin G et al., Int J Infect Dis 2024 (PMID 38570134)", {
    x: 0.4, y: 5.3, w: 9.2, h: 0.25, fontSize: 9, color: GRAY_RULE, italic: true, fontFace: "Calibri"
  });
}

// ─── SLIDE 9: DIFFERENTIAL DIAGNOSIS ─────────────────────────────────────────
twoColSlide(
  "Differential Diagnosis",
  "Conditions That Mimic Scabies in Children",
  "Commonly Confused",
  [
    "Atopic dermatitis – chronic, family history of atopy",
    "Papular urticaria – flea/insect bites, non-contagious",
    "Contact dermatitis – localized, identifiable trigger",
    "Impetigo – yellow crusting, often face",
    "Chickenpox – vesicles in crops, fever, dewdrop morphology",
    "Insect bite reactions – linear groupings, exposed areas"
  ],
  "Key Distinguishing Features",
  [
    "Multiple family members itching simultaneously → SCABIES",
    "Nocturnal worsening → SCABIES",
    "Interdigital burrows → pathognomonic",
    "Penile/scrotal nodules in boys → highly suggestive",
    "Vesiculopustules on palms/soles in infants → SCABIES",
    "No response to standard eczema treatment → reconsider scabies"
  ],
  { source: "Sources: Rosen's EM, p.2411 | Fitzpatrick's Dermatology" }
);

// ─── SLIDE 10: DIAGNOSIS ──────────────────────────────────────────────────────
bulletSlide(
  "Diagnosis",
  "Clinical First, Microscopy Confirmatory",
  [
    "CLINICAL DIAGNOSIS: primarily based on history and physical examination",
    "Key history: nocturnal itch, multiple household contacts affected, recent exposures",
    "Skin scraping (mineral oil or KOH prep) – identify mite, eggs, or scybala (fecal pellets)",
    "  • Scrape from burrow terminus or fresh papule; examine under low power (10x)",
    "  • Sensitivity is LOW (~50%) – negative scraping does NOT rule out scabies",
    "Dermoscopy – Handheld dermatoscope: 'delta-wing jet' sign",
    "  • Triangular brown mite at burrow end; high sensitivity in trained hands",
    "In vivo reflectance microscopy and PCR – higher sensitivity; not routine",
    "Treat empirically if clinical suspicion is high, especially in infants",
    "Mandatory: examine ALL household contacts regardless of symptoms"
  ],
  { source: "Sources: AAP Red Book 2021, p.1031 | Family Medicine Textbook, p.946 | Fitzpatrick's Dermatology" }
);

// ─── SLIDE 11: TREATMENT OVERVIEW ────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_LIGHT };
  addHeaderBar(s, "Treatment Overview", "Evidence-Based Management");
  // Three treatment boxes
  const boxes = [
    { x: 0.2, label: "First-Line", drug: "Permethrin 5%\nCream", color: TEAL_DARK },
    { x: 3.6, label: "Second-Line / Alternative", drug: "Oral Ivermectin\n200 μg/kg", color: TEAL_MID },
    { x: 7.0, label: "Alternative (Infants)", drug: "Sulfur 5–10%\nin Petrolatum", color: "5B8A4A" }
  ];
  boxes.forEach(b => {
    s.addShape(pres.ShapeType.rect, { x: b.x, y: 1.15, w: 2.9, h: 1.5, fill: { color: b.color }, rectRadius: 0.1 });
    s.addText(b.label, { x: b.x, y: 1.15, w: 2.9, h: 0.4, fontSize: 11, bold: true, color: AMBER, align: "center", fontFace: "Calibri", margin: 0 });
    s.addText(b.drug, { x: b.x, y: 1.55, w: 2.9, h: 1.1, fontSize: 16, bold: true, color: WHITE, align: "center", fontFace: "Calibri", valign: "middle" });
  });
  const notes = [
    "PERMETHRIN 5% cream: Drug of choice in children (approved ≥2 months); apply neck-to-toe (+ face/scalp in infants & young children)",
    "  • Apply before bedtime, leave on 8–14 hours, wash off; repeat in 7–14 days",
    "  • Kills mites AND eggs (ovicidal) – major advantage",
    "ORAL IVERMECTIN: 200 μg/kg × 2 doses (7–14 days apart) – NOT ovicidal, hence 2-dose regimen",
    "  • Cochrane review: as effective as permethrin; FDA not approved for scabies; use off-label",
    "  • Not established safe in children < 15 kg; use permethrin in this group",
    "SULFUR 5–10% in petrolatum: Safe in infants < 2 months; apply for 3 consecutive nights",
    "CROTAMITON 10%: Alternative; NOT FDA-approved for children; lower efficacy",
    "LINDANE: Last resort only – neurotoxicity risk; NOT recommended in children"
  ].map((b, i, arr) => ({
    text: b.startsWith("  •") ? b.replace("  •", "").trim() : b,
    options: { bullet: b.startsWith("  •") ? { indent: 25 } : true, fontSize: 14, color: SLATE, bold: b.startsWith("PERMETHRIN") || b.startsWith("ORAL") || b.startsWith("SULFUR") || b.startsWith("CROTAMITON") || b.startsWith("LINDANE"), breakLine: i < arr.length - 1 }
  }));
  s.addText(notes, { x: 0.3, y: 2.75, w: 9.4, h: 2.6, fontFace: "Calibri", valign: "top" });
  s.addText("Sources: AAP Red Book 2021 | Cochrane Review (Mbuagbaw et al. Br J Dermatol 2024, PMID 37625798)", {
    x: 0.3, y: 5.38, w: 9.4, h: 0.2, fontSize: 9, color: GRAY_RULE, italic: true, fontFace: "Calibri"
  });
}

// ─── SLIDE 12: AGE-SPECIFIC DOSING ───────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_LIGHT };
  addHeaderBar(s, "Age-Specific Treatment Guide", "Pediatric Dosing at a Glance");

  const rows = [
    ["Age Group", "First Choice", "Application Area", "Special Notes"],
    ["< 2 months", "Sulfur 5–10%\nin petrolatum", "Whole body incl. face, scalp", "3 consecutive nights; permethrin not approved"],
    ["2 months – 2 years", "Permethrin 5% cream", "Neck DOWN + face & scalp", "Repeat in 7–14 days; trim & treat under nails"],
    ["2 – 12 years", "Permethrin 5% cream", "Neck to toe + face/scalp if involved", "Repeat in 7–14 days"],
    ["> 12 years / ≥15 kg", "Permethrin 5% cream\nor Oral Ivermectin 200 μg/kg", "Neck to toe (adults)", "Ivermectin × 2 doses, 7–14 days apart; off-label"],
    ["Crusted scabies (any age)", "Permethrin 5% +\nOral Ivermectin", "Whole body; repeat applications", "Multiple ivermectin doses; keratolytics; derm consult"],
    ["Pregnancy / Nursing", "Permethrin 5% cream", "Neck to toe", "Ivermectin safety not established – avoid"]
  ];

  const colW = [1.7, 2.2, 2.4, 3.0];
  const startX = 0.25;
  const startY = 1.15;
  const rowH = 0.65;
  rows.forEach((row, ri) => {
    let cx = startX;
    row.forEach((cell, ci) => {
      const isHeader = ri === 0;
      s.addShape(pres.ShapeType.rect, {
        x: cx, y: startY + ri * rowH, w: colW[ci], h: rowH,
        fill: { color: isHeader ? TEAL_DARK : (ri % 2 === 0 ? "F0FAFC" : WHITE) },
        line: { color: TEAL_MID, width: 0.5 }
      });
      s.addText(cell, {
        x: cx + 0.05, y: startY + ri * rowH + 0.04, w: colW[ci] - 0.1, h: rowH - 0.08,
        fontSize: isHeader ? 12 : 11,
        bold: isHeader,
        color: isHeader ? WHITE : SLATE,
        fontFace: "Calibri",
        valign: "middle"
      });
      cx += colW[ci];
    });
  });
  s.addText("Sources: AAP Red Book 2021, p.1051–1052 | Rosen's EM, p.2411", {
    x: 0.3, y: 5.42, w: 9.4, h: 0.18, fontSize: 9, color: GRAY_RULE, italic: true, fontFace: "Calibri"
  });
}

// ─── SLIDE 13: APPLICATION TECHNIQUE ─────────────────────────────────────────
bulletSlide(
  "Permethrin Application – Step-by-Step",
  "Getting It Right: Common Mistakes to Avoid",
  [
    "1. Apply to COOL, DRY skin (bathe first, dry completely, then apply)",
    "2. Cover every square centimeter from neck to toe – do not miss any area",
    "  • In infants / young children: include face, scalp, and neck",
    "3. Pay special attention to: under fingernails, toe webs, umbilicus, genitalia, nipples, skin folds",
    "4. TRIM fingernails short and apply cream under nails (common missed site)",
    "5. Best applied at BEDTIME – leave on 8–14 hours overnight, then wash off in the morning",
    "6. REPEAT application in 7–14 days to kill newly hatched larvae from surviving eggs",
    "7. Treat ALL household members and close contacts ON THE SAME DAY",
    "8. Wash all bedding, clothing worn in last 3 days in HOT water + hot dryer cycle",
    "9. Items not washable: seal in plastic bag for 1 week OR dry clean"
  ],
  { source: "Sources: AAP Red Book 2021, p.1051 | Family Medicine Textbook, p.947" }
);

// ─── SLIDE 14: CONTACT MANAGEMENT ────────────────────────────────────────────
bulletSlide(
  "Contact Management & Environmental Control",
  "Breaking the Chain of Transmission",
  [
    "Treat ALL household members simultaneously – even asymptomatic contacts",
    "  • Scabies can be transmitted 4–6 weeks before symptoms appear",
    "Close contacts (extended family, daycare staff) – prophylactic treatment is recommended",
    "School / Daycare: child may RETURN after first completed course of treatment",
    "  • Do NOT exclude or send home early from school – counter-productive and stigmatizing",
    "Bedding, towels, clothes: hot water wash (≥60°C) + hot dryer for minimum 20 minutes",
    "Non-washable items (soft toys, coats): seal in plastic bag for ≥1 week",
    "Vacuuming of furniture and carpets: recommended for non-crusted scabies",
    "Crusted scabies: more aggressive environmental decontamination required (CDC protocol)",
    "Healthcare workers: contact precautions until patient has received treatment",
    "Notify school nurse / public health if outbreak suspected"
  ],
  { source: "Sources: AAP Red Book 2021, p.1032 | Rosen's EM, p.2412" }
);

// ─── SLIDE 15: TREATMENT FAILURE ─────────────────────────────────────────────
bulletSlide(
  "When Treatment Appears to Fail",
  "Navigating Treatment Failure and Persistent Itch",
  [
    "Post-scabies itch is NORMAL and may persist 4–6 weeks after successful treatment",
    "  • Dead mites, eggs, feces retain antigenicity → continued hypersensitivity reaction",
    "Symptomatic relief: oral antihistamines (cetirizine, loratadine) + mid-potency topical corticosteroids",
    "TRUE treatment failure – consider these causes:",
    "  • Incomplete application (missed areas, insufficient overnight contact time)",
    "  • Re-infestation from untreated household contacts or fomites",
    "  • Emerging permethrin resistance (increasingly reported worldwide)",
    "  • Crusted scabies misdiagnosed as common scabies",
    "  • Non-compliance with second application",
    "If failure after 2 courses of permethrin: switch to oral ivermectin + permethrin combination",
    "Confirm diagnosis with skin scraping before escalating treatment"
  ],
  { source: "Sources: AAP Red Book 2021 | Mbuagbaw L et al. Br J Dermatol 2024 (PMID 37625798)" }
);

// ─── SLIDE 16: COMPLICATIONS ──────────────────────────────────────────────────
bulletSlide(
  "Complications",
  "Secondary Consequences in Children",
  [
    "SECONDARY BACTERIAL INFECTION – most common complication",
    "  • Staphylococcus aureus and Group A Streptococcus (Streptococcus pyogenes)",
    "  • Presents as impetigo: yellow crusting, weeping lesions",
    "  • Treat with appropriate antibiotics (topical mupirocin or oral cephalosporin/penicillin)",
    "POST-STREPTOCOCCAL GLOMERULONEPHRITIS (PSGN)",
    "  • Scabies-associated streptococcal pyoderma is a major cause of PSGN in resource-limited settings",
    "RHEUMATIC FEVER / RHEUMATIC HEART DISEASE",
    "  • GAS skin infection from scabies infestation is a proposed pathway",
    "  • Recent 2026 systematic review highlights scabies control as potential RHD prevention strategy",
    "PSYCHOSOCIAL: stigma, sleep disruption, school absenteeism, caregiver burden",
    "ECZEMA FLARES in atopic children – superimposed scabies worsens baseline eczema"
  ],
  { source: "Sources: Rosen's EM | Gupta S et al., Australas J Dermatol 2026 (PMID 41239748) | Amgarth-Duff I et al., Trop Med Int Health 2024 (PMID 39396816)" }
);

// ─── SLIDE 17: SCABIES IN SPECIAL SITUATIONS ─────────────────────────────────
twoColSlide(
  "Scabies in Special Situations",
  "Immunocompromised, Neonates, Outbreaks",
  "Immunocompromised Children",
  [
    "High risk for crusted scabies (HIV, malnutrition, malignancy, immunosuppressants)",
    "May lack typical itch",
    "Atypical or widespread rash",
    "Combination therapy: permethrin + ivermectin (multiple doses)",
    "Dermatology and infectious disease co-management",
    "Isolation + contact precautions in hospital"
  ],
  "Outbreaks (Daycare / Hospitals)",
  [
    "Identify index case and all contacts",
    "Simultaneous treatment of all contacts",
    "Notify public health / infection control",
    "Exclude symptomatic staff until treated",
    "Environmental decontamination",
    "Education for parents and staff",
    "Follow-up at 2–4 weeks to confirm clearance"
  ],
  { source: "Sources: AAP Red Book 2021 | Bergamin G et al. 2024 (PMID 38570134)" }
);

// ─── SLIDE 18: SCABIES AND POVERTY / GLOBAL BURDEN ───────────────────────────
bulletSlide(
  "Scabies & Global Public Health",
  "NTD Status and Pediatric Implications",
  [
    "WHO declared scabies a Neglected Tropical Disease (NTD) in 2017",
    "Prevalence up to 50%+ in some Indigenous and Pacific Island communities",
    "Mass drug administration (MDA): ivermectin ± permethrin reduces community-wide prevalence",
    "  • Also reduces co-endemic impetigo and GAS infections",
    "Children bear disproportionate burden in resource-limited settings",
    "Scabies → pyoderma → GAS → acute rheumatic fever → rheumatic heart disease (cascade)",
    "Identify children from endemic regions or institutional settings with extra vigilance",
    "Barriers to treatment: cost of permethrin, access to healthcare, caregiver literacy",
    "Advocate for school-based and community-based screening programs in high-risk areas"
  ],
  { source: "Sources: WHO NTD list | Schneider 2023 (PMID 37147907) | Gupta 2026 (PMID 41239748)" }
);

// ─── SLIDE 19: CASE VIGNETTE ──────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_LIGHT };
  addHeaderBar(s, "Case Vignette", "Test Your Approach");
  s.addShape(pres.ShapeType.rect, { x: 0.3, y: 1.15, w: 9.4, h: 1.3, fill: { color: AMBER }, rectRadius: 0.08 });
  s.addText(
    "A 14-month-old boy presents with a 3-week history of severe nocturnal pruritus and a widespread papular rash. His 4-year-old sister and mother also complain of itching. Examination reveals vesiculopustules on his palms and soles, papules on the face and scalp, and crusted excoriations in the axillae.",
    { x: 0.4, y: 1.2, w: 9.2, h: 1.2, fontSize: 14, color: TEAL_DARK, fontFace: "Calibri", bold: false, valign: "middle" }
  );
  const qItems = [
    { text: "Q1: What is the most likely diagnosis?", options: { bold: true, color: TEAL_DARK, breakLine: true, fontSize: 15 } },
    { text: "Scabies – key clues: nocturnal itch, household clustering, vesiculopustules on palms/soles, face and scalp involvement in infant", options: { color: SLATE, breakLine: true, fontSize: 14 } },
    { text: "Q2: What treatment would you prescribe for this infant?", options: { bold: true, color: TEAL_DARK, breakLine: true, fontSize: 15 } },
    { text: "Permethrin 5% cream (approved ≥ 2 months): apply to entire body INCLUDING face, scalp, neck overnight × 2 applications (7–14 days apart). Treat mother and sibling simultaneously.", options: { color: SLATE, breakLine: true, fontSize: 14 } },
    { text: "Q3: What advice do you give about the sister's school attendance?", options: { bold: true, color: TEAL_DARK, breakLine: true, fontSize: 15 } },
    { text: "She may return to school after completing the FIRST course of treatment – no prolonged exclusion needed.", options: { color: SLATE, fontSize: 14 } }
  ];
  s.addText(qItems, { x: 0.3, y: 2.55, w: 9.4, h: 2.85, fontFace: "Calibri", valign: "top" });
}

// ─── SLIDE 20: WHEN TO REFER ──────────────────────────────────────────────────
bulletSlide(
  "When to Refer",
  "Indications for Specialist Involvement",
  [
    "DERMATOLOGY referral:",
    "  • Crusted / Norwegian scabies",
    "  • Failure after 2 adequate courses of treatment",
    "  • Diagnostic uncertainty despite scraping",
    "  • Widespread eczematous reaction or nodular post-scabetic syndrome",
    "INFECTIOUS DISEASE referral:",
    "  • Crusted scabies in an immunocompromised child",
    "  • Nosocomial outbreak or suspected institutional epidemic",
    "  • Secondary sepsis from superinfected lesions",
    "NEPHROLOGY: if haematuria/proteinuria develops after scabies-associated pyoderma (? PSGN)",
    "CARDIOLOGY / RHEUMATOLOGY: if features of acute rheumatic fever emerge",
    "PUBLIC HEALTH notification: institutional or cluster outbreaks"
  ],
  { source: "Sources: AAP Red Book 2021 | Rosen's EM | Dermatology 2-Vol Set 5e" }
);

// ─── SLIDE 21: PATIENT & FAMILY EDUCATION ────────────────────────────────────
bulletSlide(
  "Patient & Family Education",
  "Key Messages to Communicate",
  [
    "Scabies is NOT caused by poor hygiene – reassure and reduce stigma",
    "The itching is NOT your child's fault and is very common",
    "Everyone in the household needs treatment at the same time",
    "Itching will continue for several weeks even after successful treatment – this is NORMAL",
    "  • Call us if new burrows, new family members develop itch, or lesions worsen after 4 weeks",
    "Wash all bedding, towels, and clothing worn in the last 3 days in hot water",
    "Soft toys that cannot be washed: seal in a bag for 1 week",
    "Your child can go back to school / daycare after the first treatment",
    "Make sure the cream is applied EVERYWHERE – including under nails and skin folds",
    "Follow up in 2–4 weeks to confirm treatment success"
  ],
  { source: "Sources: AAP Red Book 2021 | CDC Scabies Patient Information" }
);

// ─── SLIDE 22: KEY TAKEAWAYS ──────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_DARK };
  s.addShape(pres.ShapeType.rect, { x: 0, y: 5.3, w: 10, h: 0.33, fill: { color: AMBER } });
  s.addText("KEY TAKEAWAYS", {
    x: 0.5, y: 0.15, w: 9, h: 0.7,
    fontSize: 28, bold: true, color: WHITE, fontFace: "Calibri", align: "center", charSpacing: 3
  });
  const keys = [
    ["1", "Think scabies when multiple household members itch – especially nocturnally"],
    ["2", "Infants & toddlers: involve face, scalp, palms, soles – don't miss these sites"],
    ["3", "Permethrin 5% cream: drug of choice; safe from 2 months; repeat at day 7–14"],
    ["4", "Sulfur 5–10% in petrolatum: safe option for infants < 2 months"],
    ["5", "Treat ALL contacts on the same day to prevent re-infestation"],
    ["6", "Persistent itch ≠ treatment failure; may last weeks due to residual antigens"],
    ["7", "Crusted scabies = emergency: contact precautions + combination therapy immediately"],
    ["8", "Scabies-related streptococcal pyoderma can lead to PSGN and rheumatic heart disease"]
  ];
  keys.forEach(([num, text], i) => {
    const col = i < 4 ? 0 : 1;
    const row = i % 4;
    const xPos = col === 0 ? 0.25 : 5.1;
    const yPos = 0.98 + row * 1.02;
    s.addShape(pres.ShapeType.ellipse, { x: xPos, y: yPos, w: 0.42, h: 0.42, fill: { color: AMBER } });
    s.addText(num, { x: xPos, y: yPos, w: 0.42, h: 0.42, fontSize: 14, bold: true, color: TEAL_DARK, align: "center", fontFace: "Calibri", valign: "middle" });
    s.addText(text, { x: xPos + 0.5, y: yPos + 0.01, w: 4.35, h: 0.42, fontSize: 13, color: WHITE, fontFace: "Calibri", valign: "middle" });
  });
}

// ─── SLIDE 23: QUICK REFERENCE CARD ──────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_LIGHT };
  addHeaderBar(s, "Quick Reference Card", "Scabies Management at a Glance");

  const sections = [
    { label: "DIAGNOSE", color: TEAL_DARK, x: 0.2, items: ["Nocturnal itch in ≥1 household contact", "Burrows (pathognomonic)", "Vesiculopustules on palms/soles (infants)", "Dermoscopy: 'delta-wing jet' sign"] },
    { label: "TREAT (FIRST LINE)", color: TEAL_MID, x: 3.4, items: ["Permethrin 5% (age ≥ 2 mo)", "Apply neck-to-toe + face/scalp in infants", "Leave on 8–14 h overnight", "Repeat at day 7–14"] },
    { label: "MANAGE CONTACTS", color: "5B8A4A", x: 6.6, items: ["Treat ALL household members", "Same-day application for all", "Hot-wash bedding & clothes", "School: return after 1st treatment"] }
  ];

  sections.forEach(sec => {
    s.addShape(pres.ShapeType.rect, { x: sec.x, y: 1.15, w: 3.0, h: 3.8, fill: { color: sec.color } });
    s.addText(sec.label, { x: sec.x, y: 1.15, w: 3.0, h: 0.42, fontSize: 12, bold: true, color: AMBER, align: "center", fontFace: "Calibri", margin: 0 });
    const items = sec.items.map((t, i, arr) => ({ text: t, options: { bullet: true, fontSize: 13, color: WHITE, breakLine: i < arr.length - 1 } }));
    s.addText(items, { x: sec.x + 0.1, y: 1.62, w: 2.8, h: 3.25, fontFace: "Calibri", valign: "top" });
  });

  // Warning box
  s.addShape(pres.ShapeType.rect, { x: 0.2, y: 5.05, w: 9.6, h: 0.48, fill: { color: RED_WARN } });
  s.addText("⚠  CRUSTED SCABIES: Contact precautions immediately + Permethrin 5% + Oral ivermectin (200 μg/kg × multiple doses) + Dermatology referral", {
    x: 0.2, y: 5.05, w: 9.6, h: 0.48, fontSize: 12, bold: true, color: WHITE, align: "center", fontFace: "Calibri", valign: "middle"
  });
}

// ─── SLIDE 24: REFERENCES ─────────────────────────────────────────────────────
{
  const s = pres.addSlide();
  s.background = { color: TEAL_DARK };
  addHeaderBar(s, "References & Evidence Base", "");
  const refs = [
    "1.  AAP Red Book 2021 – Report of the Committee on Infectious Diseases (Scabies, pp. 1031–1033)",
    "2.  Rosen's Emergency Medicine: Concepts and Clinical Practice, 9e – Scabies, p. 2411",
    "3.  Fitzpatrick's Dermatology, 9e – Scabies Chapter",
    "4.  Family Medicine Textbook (Usatine), 9e – p. 946–947",
    "5.  Dermatology 2-Volume Set, 5e (Bolognia) – Scabies Chapter",
    "6.  Schneider S et al. Prevalence of scabies worldwide–2022 update. J Eur Acad Dermatol Venereol. 2023 Sep. PMID 37147907",
    "7.  Mbuagbaw L et al. Failure of scabies treatment: systematic review & meta-analysis. Br J Dermatol. 2024 Jan. PMID 37625798",
    "8.  Bergamin G et al. Immunosuppressive risk factors for crusted scabies. Int J Infect Dis. 2024 Jun. PMID 38570134",
    "9.  Amgarth-Duff I et al. Treatment of skin conditions in resource-limited settings. Trop Med Int Health. 2024 Nov. PMID 39396816",
    "10. Gupta S et al. Scabies and Rheumatic Heart Disease prevention. Australas J Dermatol. 2026 Feb. PMID 41239748",
    "11. Strong M, Johnstone P. Cochrane Review: Interventions for treating scabies. Cochrane Database Syst Rev. 2007.",
    "12. WHO – Scabies as Neglected Tropical Disease (2017)"
  ];
  const refItems = refs.map((r, i, arr) => ({ text: r, options: { breakLine: i < arr.length - 1, fontSize: 12, color: "C8E6EF" } }));
  s.addText(refItems, { x: 0.35, y: 1.18, w: 9.3, h: 4.3, fontFace: "Calibri", valign: "top" });
  s.addText("This CME module is intended for educational purposes for pediatric healthcare professionals.", {
    x: 0.35, y: 5.36, w: 9.3, h: 0.2, fontSize: 9, color: GRAY_RULE, italic: true, fontFace: "Calibri"
  });
}

// ─── WRITE FILE ───────────────────────────────────────────────────────────────
pres.writeFile({ fileName: "/home/daytona/workspace/scabies-cme/Scabies_CME_Pediatrics.pptx" })
  .then(() => console.log("✅ Presentation written successfully."))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

cd /home/daytona/workspace/scabies-cme && node build.js 2>&1

ls -lh /home/daytona/workspace/scabies-cme/Scabies_CME_Pediatrics.pptx

ls -lh /home/daytona/workspace/scabies-cme/Scabies_CME_Pediatrics.pptx && echo "…