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
============

Testicular torsion occurs in the prenatal or the postnatal period, which is scarcely recognized in neonates[@B1]. Fertility might be lost without immediate surgical operation on diagnosing it[@B1]. The authors promptly diagnosed and managed the testicular torsion in inguinal region in an extremely low birth weight infant (ELBWI). We report this case taking account of the fact that there have not been any case reports on the occurrence of testicular torsion in inguinal region in an ELBWI.

Case report
===========

A 24-week, 745-g appropriate-for-gestational-age boy was born by vaginal delivery. The pregnancy was complicated by the onset of premature labor and Apgar scores were 3 at 1 minute, 5 at 5 minutes. He was intubated immediately right after the birth in the delivery room, given surfactant and put on a conventional ventilator for the treatment of respiratory distress syndrome. At the initial physical examination of birth, the testes were palpable in both of the inguinal regions because of the cryptorchidism with no other specific findings. However, apparent specifics were not noticed.

At 23 days of age, a newly recognized firm and enlarged 2×2 cm mass was observed in the left inguinal region where the previously described undescended testis was located ([Fig. 1](#F1){ref-type="fig"}). It was an emergency and evaluated by the ultrasound of the inguinal canal as quickly as possible. There was no blood flow in the left testis, but heterogeneous echogenicity was observed by Color Doppler ultrasonography. Contralateral inguinal area was normal and testis was not palpable in the right scrotum. Consequently, unilateral testicular torsion was suspected in the left inguinal region, which made us perform an emergency exploration under general anesthesia. Tunica vaginalis covering the left testis appeared to represent dark blue color on surgical operation. Fluid in the incised tunica vaginalis was drained. The left testis was subtly discolored pink and twisted, but was not necrotic in appearance ([Fig. 2](#F2){ref-type="fig"}). The spermatic cord was edematous and the hematoma was observed around the cord. After checking potential viability in the left testis through manual reduction, we performed left orchiopexy ([Fig. 3](#F3){ref-type="fig"}). The contralateral testis was not operated because it was an ELBWI and respiratory distress made it unlikely to persevere the operation under general anesthesia.

At 4-month follow-up after orchiopexy, both testes remained within the scrotum with good flow on ultrasound. There was no recurrence after the discharge from neonatal intensive care unit.

Discussion
==========

Neonatal testicular torsion is divided into two groups. One is prenatal testicular torsion presenting at birth. The other is postnatal testicular torsion occurring within the first 30 days of life[@B2]. 72.4% of neonatal torsion is prenatal and 27.5% postnatal[@B2]. In our case, testicular torsion occurred at 23 days of age, which fell into postnatal category. In spite of the speculation that the torsion might have been perinatal at birth, both testes were palpable in inguinal area and there was no discoloration. Besides, the perinatal torsion of the spermatic cord is normally irrelevant to prematurity and low birth weight, and it occurs bilaterally[@B2]. To summarize, considering that our case is unilateral testicular torsion in the left inguinal region and diagnosed in an ELBWI, it can be confirmed as postnatal torsion.

Testicular torsion can also be divided into \"intravaginal\" and \"extravaginal\" torsion[@B3]. Intravaginal torsion is seen mostly in older children and adult, which is related with tunica vaginalis that not only surrounds the testicle and most of the epididymis, but also surrounds the spermatic cord allowing free ration of the structures within the tunica[@B3]. On the other hand, extravaginal torsion is seen mainly in neonates[@B3], which is associated with the lack of tunica vaginalis attachment to the scrotum[@B4], occurring at the level of the spermatic cord[@B5]. However, one distinctive feature of intravaginal torsion of our case is that it is observed in an ELBWI and at 23 days of age.

The etiology of neonatal testicular torsion is unclear[@B1], [@B6], [@B7]. Especially, the cause of torsion in the undescended testes has not been found yet[@B8]. But we assume the causes of the testicular torsion in our case as follows.

First, the undescended testis can be the cause of the testicular torsion. The torsion within the inguinal canal is rare despite the fact that 75% of undescended testes are located there[@B8]. However, as suggested in a report, testicular torsion can be one of the complications of the cryptorchism[@B9]. The incidence of cryptorchism in preterm babies is 30%, which is much higher than that of fullterm infants\' 3.4%[@B8], [@B9]. Considering this, the testicular torsion is likely to occur in preterm infants with high incidence of undescended testes.

Second, the warm inguinal region of the lower abdomen and debris of the intra-abdomen may inhibit the migration of the undescended testes and cause the testicular torsion through the incomplete closure of the process vaginalis. The testicular descent into the scrotum requires lower temperature, which is cooling hypothesis of the testes in human[@B9], [@B10]. The infant in our case had bloody stool 2 days before the presentation of the testicular torsion, which made us suspect necrotizing enterocolitis stage IB. Thinking that the necrotizing enterocolitis made testes in inguinal canal warmer and debris from intestinal mucosa descend into tunica vaginalis through a patent process vaginalis, we supposed that this intestinal inflammation had stimulated the testicular torsion. Consequently, we need to consider the possibility of testicular torsion in preterm and newborn infants who have undescended testes with intestine infections such as necrotizing enterocolitis or enteritis.

Though the prophylactic fixation of contralateral testis is recommended, we left the other normal part not being operated. That was because we considered that this infant with extremely low birth weight might have the poor rates of surgical salvage and the high surgical and anesthetic risks.

The salvage rate of the testicular torsion is in between 20% to 40%, depending on the prompt surgical intervention[@B8]. In the experimental models of testicular ischemia, spermatogenesis is lost after 6 hours and endocrine secretion ceases at 10 hours[@B4], [@B7]. Besides, when patients with testicular torsion were followed up without immediate surgery, affected testis showed progressive atrophy[@B3], [@B5]. Therefore, our emergent operation was thought to be done right after the immediate diagnosis because there was neither discoloration nor ischemia of the left testis. Moreover, at 4 months post operative follow-up, this patient had normal blood flow by color Doppler ultrasound of testes. And there was no recurrence observed even after one year. Regular long-term follow-up is essential, however, to determine endocrine and fertility potential as an anorchia.

![A firm and enlarged 2×2 cm mass was observed in the left inguinal region.](kjped-53-852-g001){#F1}

![The left testis was subtly discolored pink and twisted.](kjped-53-852-g002){#F2}

![The left orchiopexy was performed after evaluating the potential viability.](kjped-53-852-g003){#F3}