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

Ischemic colitis usually results from atherosclerosis and low blood flow. Acute colonic ischemia is a common cause of colitis in the elderly, in whom colonic ischemia is a cause of morbidity. However, ischemic colitis involving the cecum alone is quite rare, with only a few case reports in the literature. Isolated ischemic involvement of the right colon has been reported with increasing frequency, particularly in association with shock \[[@B1],[@B2]\]. Cecal infarction presents with right lower quadrant pain, and therefore may resemble acute appendicitis. As this variant of ischemic colitis is less common, it may not be considered in the differential diagnosis of right lower quadrant pain. Given the possibility of cecal perforation, an early diagnosis and surgical treatment are very important factors in such cases. Little is known about postoperative ischemic necrosis of the remaining colon after surgical treatment of isolated cecal necrosis. Here, we report four patients with isolated cecal necrosis mimicking acute appendicitis seen at our institution within a 4-year period.

Case presentation
=================

This series is a retrospective analysis of isolated cecal necrosis cases diagnosed and treated at Inonu University Turgut Ozal Medical Center between July 2004 and June 2008. After a detailed examination of the medical records, four patients with confirmed diagnoses of isolated cecal necrosis were identified. Data regarding their age, sex, clinical presentation, comorbid diseases, imaging findings, treatment modality, and follow-up were reviewed. The results of hematological and biochemical analyses were evaluated, including the hemoglobin level, white blood cell count, lactate dehydrogenase, and alkaline phosphatase, as well as plain X-rays, abdominal ultrasound (US), and computed tomography (CT) of the abdomen.

The patients consisted of two men and two women with a mean age at diagnosis of 59 years (range 46-68). The patients were Turkish ethnic origin. All patients presented at the emergency room with acute abdominal pain and had symptoms of abdominal pain, nausea, and vomiting. Acute appendicitis was considered in all of the patients pre-operatively. The medical histories of three patients revealed end-stage renal failure requiring hemodialysis. The other patient had chronic obstructive pulmonary disease. The patients\' laboratory findings and clinical characteristics are shown in Table [1](#T1){ref-type="table"}.

###### 

Patient characteristics and laboratory findings

  Age, sex   Comorbid diseases   WBC      Hb (g/dL)   LDH (U/L)   CK (U/L)   Treatment             Follow-up (months)
  ---------- ------------------- -------- ----------- ----------- ---------- --------------------- --------------------
  58, F      CRI, DM, HT         23,700   11.1        618         238        Right hemicolectomy   17
  68, F      CRI                 16,400   16.5        323         647        Right hemicolectomy   19
  64, M      COPD                19,400   12.1        911         50         Right hemicolectomy   25
  46, M      CRI                 21,000   13.6        262         719        Cecum resection       37

CRI, chronic renal insufficiency; DM, diabetes mellitus; HT, hypertension; COPD, chronic obstructive pulmonary disease; WBC, white blood cell count; Hb, hemoglobin; LDH, lactate dehydrogenase; CK, Creatine Kinase.

There were no specific signs in the patients\' pre-operative plain X-rays. Abdominal US revealed free intra-abdominal fluid in one patient, while the results of abdominal US were normal in the other patients. Only one patient underwent CT, the results of which were normal. In one patient, a diagnosis of cecal necrosis was made at diagnostic laparoscopy. At laparotomy, isolated cecal necrosis and a normal appendix were seen in all patients (Figure [1](#F1){ref-type="fig"}). Three patients were treated with right hemicolectomy, and the remaining one patient was treated with cecum resection. Histopathological examinations revealed acute ischemic changes with transmural necrosis and serositis isolated in the cecum in all patients (Figure [2](#F2){ref-type="fig"}). None of the patients showed mesenteric vascular occlusion. There were no postoperative complications, and the median follow-up period was 24.5 (range: 17-37) months.

![**Isolated cecal necrosis and a normal appendix**.](1752-1947-0003-0000007443-1){#F1}

![**Histopathological examinations revealed acute ischemic changes with transmural necrosis**.](1752-1947-0003-0000007443-2){#F2}

Discussion
==========

Colonic ischemia is an significant cause of morbidity in the elderly. The causes of colonic ischemia can be classified as occlusive and non-occlusive \[[@B3]\]. Occlusive factors include atherosclerosis, thromboembolization, venous occlusion, and mechanical bowel obstruction. Non-occlusive colonic ischemia is due to a low-flow state (shock), which causes mesenteric vasoconstriction \[[@B1]\]. Isolated cecal necrosis can follow atherosclerotic or thromboembolic occlusion of the cecal arteries. Non-occlusive cecal infarction has been reported to occur in association with open-heart surgery, chronic heart disease, certain drugs, and hemodialysis \[[@B4]\]-\[[@B7]\].

Hemodialysis patients are at increased risk of ischemic colitis because they have accelerated rates of arterial vascular disease \[[@B8]\]. In addition, hypotension is common during dialysis as large amounts of fluid are removed during the procedure. Our three patients with end-stage renal disease underwent dialysis 3-4 times per week. We evaluated the patients\' blood pressure during dialysis before the development of cecal necrosis, and a decrease to 60/40 was observed.

One patient had chronic obstructive pulmonary disease (COPD). There have been no previous reports of a connection between COPD and cecal necrosis. In this patient, the histopathology was reported as hemorrhagic ischemic necrosis, with patent mesenteric arteries. The patient may have had an insufficient blood oxygen level. Overall, isolated right colon or cecal necrosis is poorly understood \[[@B9]\].

Patients with this condition present with sudden-onset predominantly colicky, right-sided lower abdominal pain. An early clinical sign is pain or pressure in the right lower abdomen, which develops to general abdominal tenderness with muscular guarding within a few to 48 hours \[[@B8]\]. The symptoms in three of our patients began 24 hours after hemodialysis. All of the patients developed abdominal tenderness, guarding, and rebound tenderness. The initial symptoms were abdominal pain and nausea.

Isolated cecal necrosis may present a diagnostic challenge, as it is an unusual, less well-known, and rather atypical presentation of acute colonic ischemia \[[@B10]\]. Diagnosis is difficult because patients present with right-sided abdominal pain and tenderness, suggesting appendicitis, cecal diverticulitis, stercoral perforation, or cecal carcinoma. At present, there is no specific serum marker for colonic ischemia. Diagnostic US has been reported to be helpful in such cases \[[@B11]\]. CT shows nonspecific findings \[[@B12]\], although cecal wall thickening with isolated pneumatosis coli are strongly suggestive of the diagnosis \[[@B13]\]. Abdominal US was performed in all of our patients, while one patient underwent abdominal CT. There were no specific signs of cecal necrosis. To make a correct diagnosis, suspicion of cecal necrosis based on the clinical history and examination is very important. The use of colonoscopy in patients with suspected ischemic colitis is controversial. Bradbury et al. cautioned that colonoscopy may increase colonic perfusion because of increased transmural pressure \[[@B14]\]. We did not perform colonoscopy in any of our patients.

Diagnostic laparoscopy may be useful for diagnosis and treatment. Based on the results of diagnostic laparoscopy, we can choose the appropriate incision type. In one of our patients, the diagnosis of cecal necrosis was made at diagnostic laparoscopy, and a middle abdominal incision was chosen. Partial cecal necrosis can be treated by laparoscopic partial cecal resection \[[@B15]\]. Open surgery was chosen for our patient because of technical problems with the laparoscopic approach at the time of surgery.

If the clinical history and examination lead to suspicion of cecal necrosis, laparotomy should be performed without delay. A middle abdominal incision should be made to allow exploration of all of the intra-abdominal organs and intestine.

The treatment of choice for isolated cecal necrosis is cecal resection or right hemicolectomy. If evidence of peritonitis persists, right hemicolectomy with anastomosis can be performed satisfactorily \[[@B16]\]. One of our patients had 1000 mL of purulent fluid in the abdominal cavity. Cecal resection with an ileocolostomy was performed in this patient, and the patient healed without complications. Right hemicolectomy with anastomosis was performed in the other three patients. The appendix was normal in all patients.

Little information is available regarding the incidence of postoperative ischemic necrosis of the remaining colon after surgical treatment of isolated cecal necrosis. The postoperative course in all of our patients was uneventful. There was no new intestinal vascular occlusion or ischemic colitis in the postoperative period.

Conclusion
==========

Isolated cecal infarction should be included in the differential diagnosis of acute right lower quadrant pain, especially in chronic dialysis patients. While ischemic diseases of the intestine have high morbidity and mortality rates, with early diagnosis and surgery, isolated cecal necrosis has a good prognosis.

Consent
=======

Written informed consent was obtained from the patients before publication of this case series and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests
===================

The authors declare that they have no competing interests.

Authors\' contributions
=======================

AD is the consultant surgeon who drafted the article and performed the operations. BU assisted in performing the surgery, took the pictures and helped revise the article. NB made the histopathologic diagnosis of the patients. CA and FT helped in surgical treatment of the patients. CK helped in acquisition of data and technical support. All authors have read and approved the final manuscript.