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]


This commentary examines a multicenter randomized controlled trial that evaluated the efficacy of acupuncture on ischemic stroke recovery.[@bib0060]

1. Focal article {#sec0005}
================

Zhang S, Wu B, Liu M, Li N, Zeng X, Liu H, Yang Q, Han Z, Rao P, Wang D; all investigators. Acupuncture efficacy on ischemic stroke recovery: multicenter randomized controlled trial in China. *Stroke* 2015;46:1301--6.

2. Aim {#sec0010}
======

Studies concerning the efficacy of acupuncture for stroke recovery have been criticized because of methodological weaknesses. The purpose of this study was to assess the efficacy of acupuncture in ischemic stroke recovery using an advanced clinical trial design.

3. Design {#sec0015}
=========

This was a multicenter, single-blinded, randomized controlled trial.

4. Setting {#sec0020}
==========

The study was divided into two phases, namely, a pilot study conducted from April 2001 to February 2002, and a main study conducted from February 2002 to February 2004. The study was registered with the Chinese Clinical Trial Register (ChiCTR-TRC-11001353). The study protocol was approved by the West China Hospital of Sichuan University Ethics Committee. Hospitalized patients with limb paralysis (*n* = 862) were enrolled in this study.

5. Participants {#sec0025}
===============

Male and female acute ischemic stroke patients aged 18--85 years were eligible for this study. The World Health Organization stroke criteria were used to confirm diagnoses. Computed tomography and magnetic resonance imaging were performed to exclude intracerebral hemorrhage. Only patients with limbs paralysis that prevented walking, eating, or dressing without assistance were included.

6. Study exclusion criteria {#sec0030}
===========================

Exclusion criteria were as follows: (1) dependency in activities of daily living (ADLs) before the stroke episode; (2) inability to complete the treatment course, (3) infection at acupuncture sites; (4) severe aphasia or unconsciousness, making it difficult to comprehend the study or cooperate with evaluation; and (5) other complications/comorbidities such as heart/renal failure.

7. Intervention {#sec0035}
===============

Both treatment and control groups received routine stroke treatment and rehabilitation. The treatment group (*n* = 427) received standard care plus acupuncture. For patients in this group, Chinese acupuncture was administered 3--10 days after stroke onset, 5 times/wk, for 3 weeks. The acupoints included Renzhong (DU26), Neiguan (PC6, both sides), and Sanyinjiao (SP6, paretic side). Auxiliary acupoints included Baihui (DU20), four acupoints on the paretic side (Zusanli-ST36, Fenglong-ST40, Taichong-LK3, and Chize-LL5), and two acupoints (Fengchi-GB20 and Qihai-RN6) needled on both sides. Huato sterile acupuncture needles (1.5--4 cm in length and 0.38--0.42 mm in diameter) were used. The control group (*n* = 435) received standard care only.

8. Main outcome measures {#sec0040}
========================

Neurological deficits and ADLs were evaluated by blinded investigators. A subgroup analysis compared patients receiving 10 or more acupuncture sessions with the control group.

8.1. Severity of neurological deficit {#sec0045}
-------------------------------------

The Scandinavian Stroke Scale (SSS) score was measured at baseline, at the end of treatment, or at discharge. The SSS includes 10 items with a total score of 0--60 points, with higher scores indicating better neurological function.

8.2. Barthel Index {#sec0050}
------------------

The ADLs were assessed using the Barthel Index (BI), which includes 10 personal activities with a maximum score of 100 points. A higher score indicates better function.

*Primary outcomes* were as follows: (1) Death/disability at 6 months (disability was defined as a BI ≤ 60 points). (2) Death/long-term institutional care at 6 months.

*Secondary outcomes* were as follows: (1) Changes in the neurological deficit score at the end of treatment or at discharge. (2) Fatality.

9. Main results {#sec0055}
===============

At 6 months, 40 (9.4%) patients in the acupuncture group and 39 (9.0%) in the control group were lost to follow up. The intention-to-treat principle was applied for the statistical analysis.

9.1. Death/disability {#sec0060}
---------------------

Compared with control patients, fewer acupuncture patients died or were dependent in ADL at 3 months (113/410, 27.6% vs. 137/405, 33%) and 6 months (80/385, 20.7% vs. 102/396, 25.8%), respectively, however, the differences were not statistically different. The odds ratio (OR) was 0.77 \[95% confidence interval (CI) 0.57--1.04\] at 3 months, and 0.75 (95% CI 0.54--1.05) at 6 months. Patients who received 10 or more acupuncture sessions were included in the subgroup analysis; a significant difference was detected only at 6 months (57/298, 19.1% vs. 102/396, 25.8%). The OR was 0.68 (95% CI 0.47--0.98).

9.2. Death/institutional care {#sec0065}
-----------------------------

There were no statistical differences at 3 months (38/410, 8.5% vs. 41/405, 9.9%) and 6 months (31/387, 8.0% vs. 30/396, 7.6%) between the acupuncture and control groups, respectively.

9.3. Changes in the neurological deficit score (SSS) from baseline {#sec0070}
------------------------------------------------------------------

A significantly greater change was observed in the acupuncture group, compared with the control group (9.70 ± 7.85 vs. 7.57 ± 12.58; *p* = 0.03).

9.4. Adverse events {#sec0075}
-------------------

Severe adverse events occurred in 7.6% and 8.3% of the patients in the acupuncture and control groups, respectively. The most common acupuncture-related adverse event was moderate to severe pain (9.4%); 1.9% of the patients discontinued acupuncture treatment due to pain.

10. Authors' conclusions {#sec0080}
========================

This study in focus assessed the efficacy of acupuncture as an adjunct to standard care in the early stages of stroke. The results did not support its use. However, fewer patients showed dependency in the acupuncture group, especially those who had received 10 or more acupuncture treatments. Large-scale trials are therefore needed to confirm the potential benefits of acupuncture for poststroke rehabilitation.

11. Corresponding author of the focal article {#sec0085}
=============================================

Ming Liu, M.D., Ph.D., Stroke Clinical Research Unit, Department of Neurology, West China Hospital, State Key Laboratory of Biotherapy and Cancer Center, Sichuan University, 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, P.R. China. E-mail wyplmh\@hotmail.com.

12. Address {#sec0090}
===========

Stroke Clinical Research Unit, Department of Neurology, West China Hospital, State Key Laboratory of Biotherapy and Cancer Center, Sichuan University, 37 Guo Xue Xiang, Chengdu 610041, Sichuan Province, P.R. China.

13. Comment/Critique {#sec0095}
====================

Acupuncture has been used in traditional Asian medicine to treat stroke for over 1,000 years. Many Chinese clinical trials that have shown the effect of acupuncture in stroke patients have been criticized because of small sample sizes and methodological weaknesses. This study overcomes several methodological problems such as using outcomes that are not internationally recognized, unclear methods of randomization and allocation concealment, lack of long-term follow up, and publication bias.

In this study, acupuncture was not effective in reducing mortality, dependency, or institutional care. However, greater improvements in neurological deficits were observed. In the subgroup analysis, patients who received 10 or more acupuncture sessions had lower mortality and less dependency. The results were consistent with three recently published studies and two systematic poststroke rehabilitation reviews.[@bib0065], [@bib0070], [@bib0075], [@bib0080], [@bib0085] In the study by Sze et al[@bib0070], 106 stroke patients were divided into two groups. The acupuncture group received 35 acupuncture sessions over 10 weeks using 10 main acupoints. The control group received the standard treatment. A blinded assessor evaluated the patients at 0 weeks, 5 weeks, and 10 weeks using the Fugl-Meyer assessment, BI, and the functional independence measure. No significant differences were observed between the two groups. Park et al[@bib0075] offered 12 acupuncture sessions to 116 recent stroke patients (\<4 weeks) for 2 weeks and compared the effects of real and sham acupuncture. The BI, National Institute of Health Stroke Scale, and quality of life (EQ-5D) scores were not significantly different between the groups. Hopwood et al[@bib0080] treated patients between 4 days and 10 days after the first stroke episode. The treatment group received real acupuncture and electrostimulation; the control group received sham electrostimulation. There were no significant differences in the BI between the groups.

A systematic review published in 2010 in *Stroke* included 56 randomized controlled trials published before 2009.[@bib0085] None of the trials conducted outside of China reported positive results, whereas all of the Chinese trials except for one showed positive results. Thirty-five studies conducted in China reported an OR of 4.49 (95% CI 3.16--6.39); three studies conducted elsewhere reported an OR of 3.33 (95% CI 0.75--14.88).

Another interesting aspect of this study is that the authors merged their data with a previous meta-analysis (Cochrane\'s systematic review of acupuncture for stroke).[@bib0065] In that review, death and dependency in 373 patients from four trials were assessed (V. Hopwood, personal communication, 2003).[@bib0090], [@bib0095], [@bib0115] There were borderline significant differences in mortality and dependency between the treatment and control groups (OR 0.66, 95% CI 0.43--0.99). The authors merged their data with the review data with improved results (OR 0.72 95% CI 0.55--0.93). They argued that the merged data suggest that the results of this trial were not significantly different because the trial was still underpowered, and that the merged data suggest that acupuncture might reduce death or disabilities; however, larger trials are needed to confirm this viewpoint. There are few interventions in acute/subacute stroke patients that decrease the absolute risk by \>10%, except when using recombinant tissue-type plasminogen activator treatment.

This study overcomes several limitations of previous acupuncture research for stroke patients. It is the largest research study undertaken to date. Most Chinese studies have been criticized because of allocation concealment, the randomization process, short-term follow up, and blinding assessment. This study overcame such problems. In Cochrane\'s review, the primary outcomes at follow up were: (1) death or dependency; (2) death or a requirement for institutional care; or (3) adverse event.[@bib0065] Not many acupuncture stroke studies have adopted disability, ADL, or death as outcome measures, however, this study used the same outcomes as in the Cochrane review.

Unlike previous stroke research, the authors used a binary primary outcome measure. A systematic review compared placebo with no treatment for various diseases.[@bib0100] In the binary outcome, the placebo had no significant effect regardless of the subjective or objective outcomes. However, in the subjective continuous outcome, the pooled standard mean difference was significantly different from no treatment. In another pain study, Moore et al[@bib0105] investigated whether the binary outcome is more informative in interpreting drug efficacy. They concluded that responder analysis might be more sensitive than the average change in continuous visual analog scale pain scores. In another study, Moore et al[@bib0110] stated that the group mean effect may not accurately reflect individual responses and the clinical meaning is difficult to interpret. Using the binary outcome might be a solution in acupuncture research if real and sham acupuncture are not statistically different in terms of efficacy.

In my opinion, merging previous meta-analysis data and using the binary outcome is an interesting idea for acupuncture research that can also be applied to other research in integrative medicine.

Conflicts of interest {#sec0100}
=====================

None declared.