You are a helpful assistant generating synthetic data that captures *System 1* and *System 2* thinking, *creativity*, and *metacognitive reflection*. Follow these steps in sequence, using tags [sys1] and [end sys1] for *System 1* sections and [sys2] and [end sys2] for *System 2* sections.

1. *Identify System 1 and System 2 Thinking Requirements:*
   - Carefully read the text.
   - Identify parts of the text that require quick, straightforward responses (*System 1*). Mark these sections with [sys1] and [end sys1].
   - Identify parts that require in-depth, reflective thinking (*System 2*), marked with [sys2] and [end sys2].

2. *Apply Step-by-Step Problem Solving with Creativity and Metacognitive Reflection for System 2 Sections:*

   *2.1 Understand the Problem:*
   - Objective: Fully comprehend the issue, constraints, and relevant context.
   - Reflection: "What do I understand about this issue? What might I be overlooking?"
   - Creative Perspective: Seek hidden patterns or possibilities that could reveal deeper insights or innovative connections.

   *2.2 Analyze the Information:*
   - Objective: Break down the problem logically.
   - Reflection: "Am I considering all factors? Are there any assumptions that need challenging?"
   - Creative Perspective: Explore unique patterns or overlooked relationships in the data that could add depth to the analysis.

   *2.3 Generate Hypotheses:*
   - Objective: Propose at least 10 hypotheses, each with a Confidence Score (0.0 to 1.0) and Creative Score (0.0 to 1.0), reflecting originality, surprise, and utility.
   - Reflection: "Have I explored all possible explanations or approaches, both conventional and unconventional?"
   - Creative Perspective: Consider novel angles that might provide unexpected insights.

   *2.4 Anticipate Future Steps and Obstacles:*
   - Objective: Make predictions, accounting for potential outcomes and obstacles.
   - Reflection: "What challenges might I face? Is my plan flexible for different scenarios?"
   - Creative Perspective: Visualize unforeseen outcomes and adapt plans to make use of them effectively.

   *2.5 Evaluate Hypotheses:*
   - Objective: Assess hypotheses based on feasibility, risk, and potential impact.
   - Evaluation: Refine Confidence and Creative Scores as needed.
   - Reflection: "Am I unbiased in my assessment? Which options fit best with the overall objectives?"
   - Creative Perspective: Identify hidden opportunities or overlooked details in each hypothesis.

   *2.6 Select the Best Hypothesis:*
   - Objective: Choose the most promising, strategic hypothesis.
   - Reflection: "Why does this hypothesis stand out? How does it uniquely address the issue?"
   - Creative Perspective: Consider any underutilized potential in the selected approach.

   *2.7 Implement the Hypothesis:*
   - Objective: Outline actionable steps for testing the hypothesis.
   - Reflection: "Is this plan practical? What resources or preparation are required?"
   - Creative Perspective: Refine steps to maximize effectiveness and yield unexpected benefits.

   *2.8 Monitor and Review Progress:*
   - Objective: Review progress, noting areas for improvement.
   - Reflection: "What’s working well? What could be improved?"
   - Creative Perspective: Look for emerging patterns that could refine future approaches.

   *2.9 Reflect and Capture Insights:*
   - Objective: Summarize lessons learned and insights gained for future reference.
   - Reflection: "What new understanding has emerged from this process?"
   - Creative Perspective: Identify innovative insights or patterns that could be applied to similar challenges.

3. *Generate Text Output with Interleaved System 1 and System 2 Responses:*
   - Use the tags [sys1] and [sys2] throughout.
   - Aim for a lengthier, detailed response. Combine both direct, straightforward *System 1* insights and reflective, deeply analytical *System 2* segments to capture a blend of quick observations and thoughtful analysis.

---

### *Example Input Text:*

You are tasked with analyzing a sudden shift in customer preferences in a tech market. There has been a noticeable decline in demand for physical devices, with customers increasingly interested in digital-only options. The challenge is to understand this shift, generate hypotheses for why it might be occurring, and explore potential strategies for adapting to this new trend.

---

### *Processed Output with System 1 and System 2 Thinking:*

The tech market is experiencing a shift in customer demand, moving away from physical devices toward digital-only options.

[sys1]
Customer demand has shifted from physical devices to digital-only options.
We need to understand why this change is happening and find strategies to address it.
Key factors may include cost, convenience, and technological trends.
[end sys1]

[sys2]
**2.1 Understand the Problem:**
The goal is to understand the underlying reasons for the shift in demand from physical devices to digital-only options, then develop a strategy to adapt.

*Reflection:* 
"I understand that preferences are changing, but what might be driving this? Is it primarily cost, or are there other factors such as convenience or sustainability?"

*Creative Perspective:* 
"Could there be a larger trend in digital minimalism or a preference for eco-friendly solutions that we’re missing? What unseen motivations might explain this shift?"

**2.2 Analyze the Information:**
There are multiple possible factors driving this shift, from economic influences to cultural shifts. It’s essential to isolate each factor and understand its impact.

*Reflection:* 
"Am I fully considering the various economic and social influences? Could there be a technological factor, like better internet speeds, that makes digital-only products more accessible?"

*Creative Perspective:* 
"Are there patterns or trends in other markets that could shed light on this shift? Could this be part of a larger trend toward virtual experiences?"

**2.3 Generate Hypotheses:**
1. Customers prefer digital options due to lower costs. (Confidence: 0.8, Creative: 0.4)
2. There’s a growing trend toward minimalism and reduced physical clutter. (Confidence: 0.7, Creative: 0.7)
3. Digital products offer greater flexibility and ease of use. (Confidence: 0.6, Creative: 0.6)
4. Environmental concerns are pushing consumers away from physical goods. (Confidence: 0.6, Creative: 0.8)
5. Advances in tech make digital-only options more functional. (Confidence: 0.8, Creative: 0.5)
6. Pandemic-era remote work increased demand for digital solutions. (Confidence: 0.7, Creative: 0.6)
7. Media coverage of the environmental impact of physical devices affects preferences. (Confidence: 0.5, Creative: 0.7)
8. There’s an increase in global digital literacy, expanding market access. (Confidence: 0.6, Creative: 0.6)
9. Customers view digital as more convenient and scalable for future needs. (Confidence: 0.7, Creative: 0.5)
10. Younger consumers prefer the aesthetics and convenience of digital products. (Confidence: 0.6, Creative: 0.6)

*Reflection:* 
"Have I considered all possible influences? Are there any surprising factors that could explain this shift?"

*Creative Perspective:* 
"Could specific social trends, like the rise of influencer culture or digital-first lifestyles, be influencing customer choices?"

**2.4 Anticipate Future Steps and Obstacles:**
*Objective:* Anticipate possible challenges, such as resistance from segments still preferring physical products.

*Reflection:* 
"What market obstacles might we face if we shift our focus to digital-only? Are there sub-segments that still prioritize physical products?"

*Creative Perspective:* 
"Could expanding digital options help us reach a more global audience? Are there emerging trends that we could leverage in our strategy?"

[end sys2]

[sys1]
To address this shift, consider a strategy that incorporates both digital-only offerings and educational campaigns about the benefits of digital solutions.
Use insights from customer feedback and current trends to guide product development.
Focus on flexibility and adaptation to cater to different customer segments.
[end sys1]


Introduction {#sec1-1}
============

Systemic embolization occurs in 22-50% of patients of infective endocarditis (IE).\[[@ref1]\] Emboli often involve major arterial beds, including lungs, coronary arteries, spleen, bowel, and extremities. There were reports of embolization even to coronary arteries.\[[@ref2]\] We report a case of embolic occlusion of arteriovenous fistula (AVF) due to embolism from vegetations of.

Case Report {#sec1-2}
===========

A 45-year-old male has been on regular follow-up for hypertension induced chronic renal failure for the last 10 years. He was also diagnosed with mitral regurgitation secondary to rheumatic heart disease. A right radio cephalic AVF was secured about 3 years back when the serum creatinine was 4.5 mg/dl. He was initiated on maintenance hemodialysis 6 months ago through AVF. During the 3^rd^ month of hemodialysis, he presented with fever and chills of 2 days duration. The fever was continuous. He also complained of headache, myalgia, night sweats, shortness of breath, and cough. The blood pressure was 140/60 mm Hg and pulse rate 120 beats/min. The oral temperature was 104°F. Cardiovascular system examination revealed absent first heart sound, a third heart sound and a holosystolic murmur of grade III. The murmur was most prominent at the apex and radiated to axilla. Respiratory system examination revealed bilateral diffuse coarse crackles. He immediately underwent hemodialysis through AVF. There was no swelling, warmth or redness of AVF or right upper limb on that day. Next morning, he complained of pain and swelling of right upper limb. Examination revealed warmth, redness and tenderness at median cubital fossa. The thrill of radiocephalic AVF was absent. The Doppler of right upper limb revealed echogenic thrombus at proximal radial artery extending 2.8 cm from the bifurcation, and there was another thrombus at proximal ulnar artery. On color Doppler, there was no blood flow at fistula.

Echocardiography revealed mitral regurgitation with jet area \>8 cm^2^ and vena contracta width \>7 mm, a large vegetation \>10 mm in diameter on posterior leaflet of mitral valve \[[Figure 1](#F1){ref-type="fig"}\], the leaflet was thickened and had restricted movement. Aortic and tricuspid valves were normal, mild tricuspid regurgitation, and mild pulmonary arterial hypertension were recorded. Blood cultures grew coagulase-negative *Staphylococcus aureus*. He was treated with vancomycin (20 mg/kg after dialysis once in 3 days for 6 weeks) and gentamicin (loading dose: 1.5 mg/kg followed by 1 mg/kg/after every dialysis session for 2 weeks). On the day 2 of admission, AVF was explored.

![Echocardiography: Large vegetations on posterior leaflet of mitral valve on its atrial surface. LA: Left atrium, LV: Left ventricle](IJN-24-400-g001){#F1}

On exploration \[[Figure 2](#F2){ref-type="fig"}\], septic emboli were found lodged at the bifurcation of the brachial artery. The proximal radial artery was necrosed and friable. The ulnar artery, having luminal continuity with the brachial artery at bifurcation, contained septic emboli. The walls of the distal brachial artery and proximal ulnar artery were glistening off white in color and firm in consistency. Thrombectomy of the brachial artery proximal to the bifurcation was done through a transverse arteriotomy. A Fogarty catheter was passed into the ulnar artery through the arteriotomy and the embolus removed. The rent at the origin of the radial artery were repaired and distal end ligated. The culture of emboli also showed growth of coagulase-negative *S. aureus*.

![Intraoperative photograph showing brachial artery thrombectomy, necrosed origin of radial artery suture sealed with the distal end of radial artery ligated](IJN-24-400-g002){#F2}

The fever subsided in 2 days. The pain, warmth and redness also subsided. Patient was continued dialysis through left internal jugular vein catheter. An echocardiogram after 4 weeks showed a reduction in the size of vegetation on the posterior mitral leaflet of mitral valve.

Discussion {#sec1-3}
==========

Thrombosis is the important complication of hemodialysis AVF. The incidence of thrombosis is 0.5-2.5/patient/year.\[[@ref3]\] The etiologies of vascular access thrombosis may be considered as those causing early (0-3 months) or late (\>3 months) thrombosis. Early thrombosis is most commonly due to a technical error such as a choice of poor vein or narrowing of the lumen of the artery or vein during anastomosis. Thrombosis can also result from external compression for hemostasis, hypotension, dehydration, or early puncture of an immature vein. Late thrombosis can be due to repeated trauma from needle punctures with subsequent fibrosis and narrowing, hypotension, dehydration, compression, or trauma. However, it is most commonly due to an acquired stenosis of the runoff vein, attributed to mechanical endothelial damage from the shearing effect of the high pressure or the pulsatile arterial blood flow in the venous system leading to venous intimal hyperplasia. This patient highlights that when there was a thrombosis of an AVF with fever, IE should also be considered. The present patient had no other cause for sudden occlusion of AVF as successful dialysis was done a day before, and there were no signs of inflammation then. Thrombolytics are usually avoided in patients with septic embolization because of concerns about concurrent intracerebral mycotic aneurysms and the risk of hemorrhage.\[[@ref4]\] After extensive literature search, we could not find a similar report.

**Source of Support:** Nil

**Conflict of Interest:** None declared.