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]


1. Introduction {#sec0005}
===============

Inflammatory myofibroblastic tumor (IMFT) is a rare soft tissue neoplasm of unclear etiology composed of myofibroblastic spindle cells accompanied by a dense inflammatory cell component [@bib0005]. It occurs primarily in soft tissue and viscera of children and young adults, although the age range extends throughout adulthood [@bib0010]. Lung is the site most commonly affected but virtually any site may be involved, including spleen, stomach, intestine, liver, mediastinum, retroperitoneum, bladder, and they can occur as single or multiple tumors [@bib0010], [@bib0015], [@bib0020], [@bib0025]. IMFT has been synonymously referred to as plasma cell granuloma, plasma cell pseudotumour, inflammatory myofibrohistiocytic proliferation, omental mesenteric myxoid hamartoma, inflammatory pseudotumour [@bib0005]. All of these share a key pathologic differentiation: a dominant spindle cell proliferation with a variable inflammatory component. These spindle cells are myofibroblasts, thus, the preferred term for reference should be IMFT reflective of this pathologic feature. Here we describe the case of a cecal IMFT presenting as an ileocecal intussusception.

2. Presentation of case {#sec0010}
=======================

Our patient was a 55-year-old man with a past history of hypertension and spine surgery. He went to our Emergency Department with a two months history of colicky abdominal pain, more intense at the right inferior abdominal quadrant. He had also unintentional weight loss of 8 kg in the previous four months. Physical examination revealed tenderness in the right inferior abdominal quadrant. Laboratory tests were normal. He was investigated with an abdominal ultrasound which revealed an image of ileocecal intussusception ([Fig. 1](#fig0005){ref-type="fig"}). The computed tomography (CT) scan revealed an image of intussusception at the cecum, the intussusceptum being a 12 mm hypodense, tubular image that seemed to be the appendix ([Fig. 2](#fig0010){ref-type="fig"}). He underwent colonoscopy which demonstrated a pediculated tubular lesion, with the base near ileocecal valve, occupying most of ascending colic lumen ([Fig. 3](#fig0015){ref-type="fig"}). Laparotomy confirmed an ileocecal intussusception with the lead point at a cecal neoplasm that reached the base of the enlarged appendix; a right hemicolectomy was performed ([Fig. 4](#fig0020){ref-type="fig"}). Postoperatively, the patient did well, without complication. He was discharged home uneventful at the 7th postoperative day ([Table 1](#tbl0005){ref-type="table"}).

On pathological examination, gross inspection of the specimen revealed a solid, well-defined mass, measuring 5 × 5 × 4.5 cm, near the base of the appendix with exophytic growth into intestinal lumen. It obstructed the appendix, causing a mucocele. Microscopically, the tumor had a proliferation of spindle cells, such as myofibroblasts and fibroblasts, and between these there was a mixed inflammatory infiltrate with eosinophils, and edematous vascularized stroma. There was no nuclear atypia or mitotic activity. Immunohistochemically, it was positive for smooth muscle actin and negative for desmin, CD34, S100, CD31, AE1AE3 and CD117. It also stained negative for ALK. This was compatible with an inflammatory myofibroblastic tumor, low grade tumor/grade 1 in the French Federation of Cancer Centers Sarcoma Group (FNCLCC) classification. The tumor was removed completely. He did well in the last 7 months.

3. Discussion {#sec0015}
=============

Different terms for IMFT have been used over the years − plasma cell granuloma, plasma cell pseudotumour, inflammatory myofibrohistiocytic proliferation, omental mesenteric myxoid hamartoma, inflammatory pseudotumour [@bib0005]. The term inflammatory pseudotumor has been used for any clinically, macroscopic or microscopic tumor-like lesion caused by an inflammatory or reactive process. Later, cytogenetic and molecular evidence supported a clonal origin, implying that it is a neoplastic process. A chromosomal rearrangement at band 2p23 is found in about half of cases, which is the site of the anaplastic lymphoma kinase (ALK) gene in the tyrosine kinase locus [@bib0015]. ALK mutations are less found in extrapulmonary IMFT. The etiology of IMFT is still unknown. Some authors think that development of IMFT occurs after trauma, surgery or infection, such as Epstein-Barr virus and human herpes virus, related with reactive cytokine production [@bib0010], [@bib0015], [@bib0020], [@bib0025], [@bib0030].

IMFTs were first well described in the lungs and later became recognized in extrapulmonary locations [@bib0010], [@bib0015], [@bib0020], [@bib0025] − 43% of extra-pulmonary involvement affects the mesentery and omentum [@bib0035]. Gastrointestinal (GI) involvement is rare however there are reports of involvement of any part of GI tract [@bib0010], [@bib0030], [@bib0035], [@bib0040], [@bib0045]. It occurs mostly in childhood and young adults but patients of any age and sex can be affected [@bib0010].

The clinical presentation is determined by the site of origin and mass effect. A constitutional syndrome consisting of fever, weight loss and malaise is seen in 15--30% of patients [@bib0015]. IMFT derived from the GI tract presents with clinical symptoms of anemia, loss of appetite or weight, fecal blood positive [@bib0010], abdominal pain, GI obstruction [@bib0045], or intussusception [@bib0050]. Our patient presented with 2 months history of abdominal pain and unintentional weight loss of 8 kg, and imaging techniques revealed it to be an ileocecal intussusception. Adult patients with intussusceptions have non-specific and often long standing symptoms, usually present for more than a month [@bib0055]. The classical image signs facilitated the diagnosis, both ultrasonography and abdominal CT scan proved to be useful tools for the diagnosis of intussusception. The classic appearance of an intussuscepted bowel on a sonographic image in a transverse plane is called the "doughnut sign" or a "target lesion" and represents several concentric rings of the bowel. The longitudinal appearance of intussusception usually appears as multiple parallel lines, the so-called "sandwich appearance" or "pseudo-kidney sign"; the lines demonstrate bowel walls and their layers [@bib0060]. Abdominal CT is currently considered as the most sensitive radiologic method to confirm intussusception, with a reported diagnostic accuracy of 58%--100% [@bib0055], [@bib0065]. CT signs of intussusception include the "target sign" or shaped soft-tissue mass with a layering effect [@bib0070]; mesenteric vessels within the bowel lumen are also typical. CT can be helpful in determining the underlying cause, locating the lead point and evaluating complications. However, both endoscopic and computed tomography examinations do not reveal any differences between an IMFT and other types of neoplasm so it is impossible to differentiate IMFT from a malignant process based on these studies. Diagnosis is based on histopathologic analysis, which usually implies surgical resection. Histologically, IMFTs are characterized by a cellular spindle cell proliferation in a myxoid to collagenous stroma with a prominent inflammatory infiltrate composed primarily of plasma cells and lymphocytes, with occasional admixed eosinophils and neutrophils [@bib0015]. Three basic histological patterns have been described: 1) fasciitis-like, with vascular, myxoid, and inflamed stroma, including plasma cells − the inflammatory infiltrate in these areas often contains more neutrophils and eosinophils and fewer plasma cells than in the other two patterns; 2) compact spindle cell pattern, that is characterized by a cellular proliferation of spindle cells with a fascicular architecture in a collagenous stroma, these foci typically show numerous plasma cells and lymphocytes intimately admixed with the spindle cells; 3) fibromatosis-like pattern is relatively hypocellular, with elongated rather than plump spindle cells in a densely collagenous background containing scattered lymphocytes, plasma cells and eosinophils, fibrosis and calcification can be seen in the stroma [@bib0035]. Pleomorphism is moderate, but mitoses are infrequently seen.

Complete surgical excision is the mainstay of treatment and provides the best chance to limit recurrence. When completely resected, with microscopically clear margins, there are virtually no recurrences [@bib0025]. Chemotherapy and radiation treatment have been used as adjuncts to surgery when the tumor is found not amenable to complete surgical resection (eg, multiple nodules), when there are positive margins or the tumor is locally aggressive [@bib0020], [@bib0025]. Nonsteroidal anti- inflammatory drug (NSAID) and steroid have been used in symptom control, usually in conjunction with other treatment modalities [@bib0020], [@bib0025]. In patients with *ALK* rearrangement, targeted kinase inhibition with crizotinib has been used. This therapy along with surgery has proved useful in cases complicated by local recurrences [@bib0075].

IMFTs are classified as tumors of intermediate biological potential by the World Health Organization classification, due to a tendency for local recurrence and a small risk of distant metastasis. The recurrence rate varies with anatomical site, from 2%, for tumors confined to the lung, to 25% for extrapulmonary lesions, usually related with incomplete surgical resection or multinodular intra-abdominal tumors [@bib0015]. The main prognostic indicator is the adequacy of the primary excision [@bib0025]. In most cases, the prognosis is good, as recurrence is infrequent following complete excision of solitary lesions and metastases are present in less than 5% of cases, usually related with tumors with atypia, ganglion-like cells, TP53 expression, and aneuploidy [@bib0005], [@bib0020], [@bib0025]. Mortality rate is low, with only few cases described in literature determining IMFT as a cause of death, mostly due to the localization of the tumor, e.g. heart [@bib0035].

Because IMFTs can recur locally, regular follow-up is necessary even when surgical resection was performed, especially in the first year, when most recurrences occur [@bib0025]. There are no guidelines for follow-up of patients with IMFTs, so an individualized approach must be planned. Our patient had a complete excision and no features of tumor aggressiveness, as such, a symptom based follow-up can be regarded as an appropriate approach.

4. Conclusion {#sec0020}
=============

IMFTs are neoplasms that occur primarily in children and young adults that rarely affect GI tract. Diagnosis is histological and the treatment is complete surgical excision. Prognosis is good as they rarely recur locally or metastasize.

Conflicts of interest {#sec0025}
=====================

None.

Funding {#sec0030}
=======

This case-report had no sponsors.

Ethical approval {#sec0035}
================

Not applicable.

Consent {#sec0040}
=======

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Author contribution {#sec0045}
===================

Cláudia Paiva -- research on bibliographic material; writing of the paper; final approval of the version to be submitted.

Filomena Soares -- research on bibliographic material and article preparation; final approval of the version to be submitted.

Raquel da Inez Correia -- research on bibliographic material and article preparation; revised critically this case report; final approval of the version to be submitted.

Vítor Valente -- revised critically this case report; final approval of the version to be submitted.

Guarantor {#sec0050}
=========

Cláudia Maria Linhas Paiva.

The authors had no study sponsors.

![Ultrasonographic image in transverse section: hypoechoic outer layer of edematous bowel wall with echogenic layers, known as the "bulls-eye" or "target" signs, which are characteristic images in intussusception.](gr1){#fig0005}

![Axial CT of the abdomen: shows the edematous wall of the intussuscipiens, the "target" sign, suggesting ileocecal intussusception.](gr2){#fig0010}

![Endoscopic examination revealed a pediculated lesion, with the base near ileocecal valve, occupying most of ascending colic lumen.](gr3){#fig0015}

![Bowel wall is cut away, revealing the mass emanating near the base of the appendix.](gr4){#fig0020}

###### 

Briefing of the case.

Table 1

  ---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------
  Identification                                                                                                               Male, 55 years old
  Medical history                                                                                                              Hypertension; spine surgery
  Chief complaint                                                                                                              Abdominal pain, strongest in right inferior quadrant
  Physical exam                                                                                                                Tenderness in the right inferior abdominal quadrant
  Diagnostic assessment                                                                                                        Laboratory tests: normal.
  Abdominal ultrasound: image of ileocecal intussusception.                                                                    
  Computed tomography scan: image of intussusception at the cecum, the intussusceptum being a 12 mm hypodense, tubular image   
  Colonoscopy: a pediculate tubular lesion, with the base near ileo-cecal valve occupying most of ascending colic lumen        
  Treatment                                                                                                                    Surgery: right hemicolectomy.
  Histopathological exam                                                                                                       Complete excision of a low grade inflammatory myofibroblastic tumor
  Outcome                                                                                                                      No complication. Discharged home at the 7thpostoperative day.
  Follow-up                                                                                                                    Without clinical recurrence at 7 months
  ---------------------------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------