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]


Chylothorax which develops following cardiac surgery in pediatric patients is a prevalent complication associated with causes of serious morbidity and mortality including severe malnutrition, impairments in hematological, metabolic and immune systems, need for a longer ventilation and prolongation of hospital stay \[[@ref1], [@ref2], [@ref3]\]. In single centered studies incidence of chylothorax following cardiac surgery has been reported as nearly 4--9% \[[@ref3], [@ref4], [@ref5]\]. Development of chylothorax can be associated with injury of the thoracic duct, disruption of lymphatic channels, increase in venous pressure and central venous thrombosis \[[@ref1]\].

For the diagnosis of chylothorax pleural fluid should appear like a milk, its culture should be sterile, triglyceride level should be higher than 110 mg/dL, and total amount of cells, and the ratio of lymphocytes should be above 1000 cells/µL, and 80%, respectively \[[@ref6]\].

Current treatment strategies include conservative methods as drainage of the pleural fluid, discontinuation of the enteral nutrition, total parenteral nutrition (TPN), feeding with formulas containing medium chain triglyceride (MCT), and in resistant cases, surgical methods as ligation of the thoracic duct, pleuro-peritoneal shunt or pleurodesis \[[@ref6], [@ref7]\]. However, surgical treatment increases morbidity rates, hospital stay and costs. In the literature, with octreotide treatment successful treatment results have been reported in unresponsive cases \[[@ref8]\]. In this case report we presented a patient who had chylothorax developed after surgical procedure because of congenital heart disease in the neonatal period.

CASE REPORT {#sec1-2}
===========

A male baby was born via cesarean section at 38 1/7 weeks gestation and birth weight of 2970 g. On antenatal ultrasound (US) atrioventricular septal defect was detected. On physical examination, the patient with respiratory distress was intubated and hospitalized in the neonatal intensive care unit. On echocardiograms complete atrioventricular channel defect, muscular ventricular septal defect and pulmonary hypertension were detected. Diuretic and inotropic treatment were initiated. Transfontanel and abdominal US findings were unremarkable. Pulmonary artery band operation was performed the postnatal 40^th^ day. Twenty days after the procedure, the patient was extubated and monitored with continuous positive airway pressure (CPAP). During monitorization, respiratory distress increased progressively and he was re-intubated. On physical examination, decreased respiratory sounds on the left hemithorax were auscultated. On telecardiogram left lung was opaque and consistent with pleural effusion ([Figure 1](#F1){ref-type="fig"}). Pleural fluid was detected 4 cm on thoracic US. For diagnosis and treatment 50 ml milky-colored fluid was evacuated with thoracentesis ([Figure 2](#F2){ref-type="fig"}). Biochemical analysis of the sample fluid was determined as follows: triglyceride, 161mg/dL, WBC 1300/mm^3^ with a 90% lymphocyte dominancy and culture negativity. One day later 50 ml fluid was drained, baby formulas containing TPN and MCT were initiated. Series pulmonary chest radiograms revealed persistence of preexisting pleural effusion, consequently, a chest tube was implanted into the left hemithorax and underwater drainage was performed. On the third day of the treatment her respiratory distress persisted, and amount of pleural fluid did not change which encouraged us to initiate three equal doses of octreotide (10 µg/kg/d/SC Sandostatin®). On the eight day of the treatment, intravenous infusion treatment with octreotide doses of 3 µg/kg/h was initiated. The dose of octreotide was increased stepwise. On the 20th day of the treatment amount of the drained fluid decreased. Control pulmonary radiogram was normal and thoracic US did not reveal any pleural effusion. ([Figure 3](#F3){ref-type="fig"}). Chest tube was removed. The patient was extubated because of regression of respiratory failure symptoms and he was monitored on nasal CPAP support. Any adverse effect secondary to octreotide treatment was not seen. The dose of octerotide was tapered and finally discontinued. The baby was gradually switched to breast feeding. Parents of our case gave their "Informed Consent" for the publication of this case report.

![On telecardiogram opacified left lung consistent with pleural effusion.](NCI-2-227-g001){#F1}

![Milky colored pleural fluid drawn by thoracentesis.](NCI-2-227-g002){#F2}

![Post-treatment control telecardiogram.](NCI-2-227-g003){#F3}

DISCUSSION {#sec1-3}
==========

Chylothorax which develops following cardiac surgery in pediatric patients is a prevalent complication associated with causes of serious morbidity and mortality. However, a complete consensus does not exist about the optimal treatment approach for chylothorax developed after surgery. In the literature, various algorithms have been developed dependent on the experience and preferences of the physicians \[[@ref3], [@ref4], [@ref9]\]. Generally, preferred method is conservative approach including discontinuation of enteral nutrition, feeding with formula containing TPN or MCT, drainage of pleural fluid and mechanical ventilation. This treatment leads to hypoproteinemia, coagulopathy, lymphopenia, hypogammaglobulinemia, sepsis and ventilation-related pulmonary injury \[[@ref10]\]. Firstly, in the year 1998, in the medical treatment of chyhlothorax developed following cardiac surgery the use of intravenous somotastatin was reported \[[@ref11]\].

Octreotide is a long-acting synthetic somatostatin analogue. Though mechanism of action of somatostatin and octreotide has not been fully elucidated, its suppressive effects on lymphatic fluid formation predominantly by vasoconstriction and resultant decrease in splenic blood flow \[[@ref12], [@ref13]\]. Somatostatin is administered as a continuous infusion, while octreotide can be also applied as subcutaneous injection. Recommended initial dose of somatostatin can be as high as 3.5 mg/kg/h, while in case of need use octreotide dose within the range of 0.3--10 µg/kg/hr is recommended \[[@ref14], [@ref15]\]. Optimal timing and dose of these two drugs have not been known so far \[[@ref12]\]. Though duration of treatment is controversial, generally treatment should be continued for 3--5 days after cessation of the drainage of the pleural fluid \[[@ref8], [@ref16]\]. During treatment with octreotide and somotatin adverse effects as hyperglycemia, hypothyroidism, muscle cramps, hypertension, nausea, diarrhea, necrotizing enterocolitis, renal involvement and hepatic dysfunction can be encountered \[[@ref17]\]. Development of anaphylaxis secondary to octreotide use has been reported \[[@ref18]\].

In the treatment of chylothorax which develops during childhood where conservative and medical treatment modalities failed, surgical treatment alternatives should be conceived. Thoracic duct ligation described by Lampson in 1948 is used prevalently in patients who did not recover with medical treatment \[[@ref19]\]. Obliteration of pleural space with surgical or chemical methods is another surgical method. To this end, tetracyclin, talc, bleomycin, and povidone iodure have been used \[[@ref17]\]. In cases where lymph leakage continues despite medical, and surgical treatment modalities, pleuroperitoneal shunt can be applied \[[@ref12]\].

In this case, intravenous octreotide was used in the treatment of chylothorax developed following cardiac surgery during neonatal period with successful outcomes. We hope that this treatment modality will take its proper place in routine clinical use after prospective controlled studies.

**Conflict of Interest:** No conflict of interest was declared by the authors.

**Financial Disclosure:** The authors declared that this study has received no financial support.