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 {#s1}
============

Implantable cardioverter defibrillators (ICD) are state of the art devices for the primary and secondary prevention of sudden cardiac death \[[@R1]\]. As a result, the use of ICDs has increased remarkably over the past years. Since they are life saving devices and because dysfunction can cause fatal pro-arrhythmia \[[@R2]\], monitoring of their proper functioning is vital for patient welfare.

To date, conventional ICD follow-up is in the form of device clinics where the ICD is interrogated and programmed periodically and the appropriate system function is ensured. Remote device monitoring has recently been introduced and may provide advantages especially for patients living further away from the implanting center \[[@R3]\]. Another important feature of current ICDs is the ability to monitor the device function and the patient clinical status, and to alert the patient if evidence for system dysfunction or adverse clinical events is found. This article gives an overview about patient alerting features of current ICDs.

Alert features related to device function {#s2}
=========================================

Programming a ventricular fibrillation (VF) detection zone with shock therapy is essential for adequate ICD function. To ensure this condition, an alert may be triggered if VF detection and / or three or more VF therapies are programmed off by mistake.

ICD battery longevity is limited and capacitor charging times increase prior to battery depletion. Thus, it is important to exchange the device in time (when the recommended replacement time is reached). Currently available alert features warn the patient in case of low battery voltage and / or because of excessive capacitor charge time \[[@R4]\].

Lead-related adverse events occur in a small but significant proportion of ICD patients \[[@R4],[@R5]\] and will probably become more frequent in the future since a growing amount of leads remains in place when generators are replaced for battery depletion. ICD lead failure may cause ineffective treatment during ventricular arrhythmia or inappropriate therapy due to oversensing of electrical noise \[[@R5],[@R6]\]. Thus, early detection of ICD lead dysfunction, ideally prior to an adverse clinical event, is essential. Alert features that monitor lead impedance can enhance the early detection of ICD lead failure \[[@R4],[@R5],[@R7]\]. Devices with this feature deliver sub-threshold impulses on a daily basis to determine the impedance within the pace-sense or high voltage circuit of the ICD lead \[[@R5],[@R8]\]. A very low lead impedance may indicate insulation failure, while a very high impedance may indicate conductor fracture. The upper and lower alert boundaries may be programmable, but typically a pacing lead impedance \<200 or \>2,500 to 3000 Ω and high-voltage lead impedance \<10 to 20 or \>200 Ω is considered abnormal and will trigger an alert.

Furthermore, an alert may be triggered if anywhere from one to six high voltage shocks occur during one single episode or if all device therapies within one tachycardia detection zone are delivered. Both of these alerts may indicate device dysfunction (e.g., ventricular oversensing) or a clinical problem like an incessant VT or atrial fibrillation with rapid atrioventricular conduction.

Alert features related to patient clinical status {#s3}
=================================================

Most ICD patients are also at risk for clinical events other than ventricular tachyarrhythmias. The so-called OptiVol™ alert feature is based on intrathoracic impedance monitoring and has been introduced in an effort to enhance the early detection of decompensating chronic heart failure (CHF) \[[@R9]\]. Observational data suggest that this alert feature can be integrated into the ambulatory management of CHF patients \[[@R9]\].

Other alert features are related to the occurrence of atrial tachyarrhythmias. An alert that warns the patient if the daily atrial tachyarrhythmia burden exceeds a programmable value may help to prevent thrombembolic events \[[@R11]\]. Another alert feature is triggered if the average ventricular rate during an atrial tachyarrhythmia episode crosses a programmable threshold, thereby preventing high ventricular rates that may lead to CHF decompensation.

Limitations of current alert features and future perspective {#s4}
============================================================

There is a broad variation in the availability of alert features between ICD models from different manufacturers. Most of the existing alert features are available in recent Medtronic ICDs. In these devices, the patient can be alerted by an audible signal, occurring once daily at a programmable time. The limitation of using an acoustic signal is that some patients may not hear the alert, while other subjects may confuse environmental noise with the device alert tone. This can result in \"phantom alerts\" that cannot be verified upon ICD interrogation. To overcome these limitations, an external device (available in Europe) that provides wireless communication with the implanted ICD can be handed out to these subjects. In case of an alert event, patients are then visually warned (signal light on). In recent devices from St. Jude Medical, vibration of the ICD is used to alert the patient of potential device dysfunction. One limitation of acoustic, visual and tactile alerts is that the patient has to contact the physician first to allow an intervention. Recent devices offer automatic remote transmission of alert events and associated diagnostic data, which may allow a more rapid event verification and intervention by the physician.

Despite obvious advantages, patient alerting features do not yet substitute for regular follow-up visits. In particular, current alert algorithms have only a limited sensitivity to detect lead-related problems \[[@R4],[@R5]\]. Lead dislocation may not be detected because pacing and sensing thresholds are not monitored. Impending ICD lead failure is often not detected sufficiently early, because sporadic measurements of impedance (once daily) are unlikely to reveal unusual findings if the structural lead defect is discrete at first and electrical integrity is lost only for brief moments (e.g. during arm movement). Continuous monitoring of lead integrity can be achieved by the Sensing Integrity Counter (SIC, Medtronic), which is a cumulative count of very short ventricular senses intervals that indicate oversensing of electrical noise. Retrospective data suggest that the combined use of SIC and impedance monitoring would result in very high sensitivity for ICD lead failure detection \[[@R5],[@R12]\]. Unfortunately, however, this feature has not yet been integrated into a patient alert algorithm.

Alert features that monitor the clinical status of ICD patients, e.g. for impending CHF decompensation or the onset of atrial tachyarrhythmias, are exciting new diagnostic tools that may improve patient management. However, it is not yet clear how these diagnostic data should be integrated into routine clinical practice, and if hard endpoints such as hospitalizations or mortality can be reduced. Large randomized controlled trials are on the way to answer these questions.