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]


NEW ORLEANS -- Some things don't add up about the transcatheter aortic valve replacement (TAVR or TAVI) data, according to allegations presented here at the Society of Thoracic Surgeons (STS) meeting.

When the PARTNER 1A trial first came out in 2011, the trialists concluded that the Sapien valve was non-inferior to surgery out to three years for patients with symptomatic severe aortic stenosis at high surgical risk.

However, some of the PARTNER 1A data were apparently "hidden" to give TAVR a leg up, Anthony Furnary, MD, of the Starr-Wood Cardiac Group of Portland, Oregon, told an STS audience.

"The medical-industrial complex, having invested billions of dollars into the development of TAVI, wanted to ensure regulatory and clinical approval ... In that quest, and to that end, they have withheld important clinical data, which has impaired the ability of the medical community at large to fully evaluate the comparative effectiveness of TAVI to isolated SAVR [surgical aortic valve replacement] and its impact on specific patient populations," Furnary alleged.

"This has irreparably altered clinicians' ability to rationally and safely deploy this excellent technology to the appropriate patient populations without concomitantly, unwillingly and unknowingly doing harm," he continued.

Furnary said he pored over the nearly 1,200 pages of meeting materials from the FDA advisory committee that advised approval of a broader high-risk indication for the Sapien TAVR valve in 2012 (it was first approved in 2011 for inoperable patients).

He found non-publicized numbers showing that TAVR was not non-inferior to SAVR in 1-year survival for men.

"The FDA was highly concerned about this, and it was mentioned no less than three times in the executive summary," Furnary said. He found that the agency had implored Edwards to look further into the issue, resulting in a 2015 meta-analysis confirming this but with a "positive spin" -- that female sex was an independent predictor of late survival after the transcatheter procedure.

Another point of contention for Furnary was "shifty" nomenclature hiding the appropriate "valve implant" comparison. Comparing apples to apples, one would see a 24.5% rate of actual TAVR implant mortality at one year compared with 21.6% for isolated SAVR (without concomitant procedures), according to his calculations, which took into account exclusions and crossovers between trial arms.

"TAVI implants failed to meet non-inferiority to isolated SAVR. In other words, SAVR is superior to TAVI," he said. "None of this was shown in PARTNER 1A."

Yet it was the surgeons who decided at the operating table whether they would do any accompanying procedures on a patient assigned to SAVR, according to fellow surgeon Vinod Thourani, MD, of Piedmont Heart Institute in Atlanta.

"If there's anyone to criticize, it's this room," he said during the session's panel discussion.

Thourani also pointed out that the The New England Journal of Medicine, in which PARTNER 1A was published, does not allow subanalyses. "We have to be careful about poo-pooing the randomized trials a little bit."

Furnary maintained that the trialists had eight years to publish the data and to tell the world that in males, TAVR was not non-inferior in the high-risk population.

"In my opinion, the series of randomized trial data that exists in the TAVR space constitutes some of the highest level of clinical evidence ever generated for a cardiovascular procedure (interventional or surgical)," said interventional cardiologist Ajay Kirtane, MD, SM, of Columbia University Irving Medical Center/NewYork-Presbyterian Hospital in New York City, in an email to MedPage Today.

"Secondary analyses [by Furnary] of what appear to be isolated subgroups and post-randomization treatment cohorts (e.g., after isolated valve implantation, within the as-treated group) are fraught with the potential for erroneous conclusions," continued Kirtane, who was not involved in PARTNER 1A.

Over the course of his STS presentation, Furnary also touched on the higher rates of early stroke and neurological events with TAVR compared to SAVR in PARTNER 1A (even with a transfemoral approach). Aortic regurgitation and reverse modeling also tended to favor the surgical group as well, he said.

"The way things don't add up, it troubles me enormously," said epidemiologist and biostatistician Nick Freemantle, PhD, of University College London. "What we don't have is a randomized trial sponsored by someone other than a manufacturer."

"Where would we be now if the French hadn't sponsored MITRA-FR? We would have a completely different view" of MitraClip for secondary mitral regurgitation, Freemantle noted as an example.

"The truth is out there. You deserve to know the truth, patients deserve to know the truth, and cardiologists need to know the truth," Furnary said. "I do TAVI. I think it's a great thing. I just have a problem with what was presented, how it was presented, and what was not presented."

However, the totality of the data, including intention-to-treat and as-treated analyses and secondary manuscripts, supports the role of TAVR as an alternative to SAVR, Kirtane argued.

"Newer devices, technique iterations, and rigorous neurologic assessments of all randomized patients (which were incorporated into subsequent trial designs in light of the recognized early stroke concerns) have demonstrated the current-day TAVR procedure to be even safer than observed in this early study," he stated.

Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow