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 article is available from: <http://casesjournal.com/casesjournal/article/view/7010>

Introduction {#s01}
============

Constrictive pericarditis is a process of chronic fibrous thickening of the pericardium, which is frequently accompanied with calcification and prevents the diastolic filling of the heart, reducing venous return and lowering output \[[@bib-001],[@bib-002]\]. Pericardial constriction is resulted from the chronic inflammation of the pericardium, which leads to pericardial scarring, thickening, fibrosis, and calcification \[[@bib-003]\]. Many etiologies have been identified, such as idiopathic chronic pericarditis, infection, after cardiac surgery, and mediastinal radiotherapy \[[@bib-002],[@bib-004],[@bib-005]\].

*Mycobaterium tuberculosis* is the most common cause of constrictive pericarditis in endemic area \[[@bib-006]\]. The definite diagnosis is based on one of the following criteria: (1) positive Mycobaterium tuberculosis culture from pericardial effusion or tissue, (2) positive acid-fast stain bacilli or typical caseous granuloma on pericardial biopsy specimen, or (3) positive tuberculosis polymerase chain reaction in the pericardial biopsy specimen \[[@bib-007]\].

Case presentation {#s02}
=================

A 63-year-old Taiwanese male patient was presented in October 2006 with progressive extremities edema, puffy face, abdominal distension and dyspnea on exertion for 2 weeks. There was no chest discomfort, orthopnea or paroxysmal nocturnal dyspnea. He did not have symptoms of cough, fever, foamy urine, or body weight loss. He had diabetes mellitus for years, which was well controlled with insulin. Physical examination revealed generalized pitting edema with elevated jugular venous pressure, positive Kussmaul\'s sign, and hepatomegaly. Bilateral pleural effusion, patchy infiltration at right middle lung field, and cardiomegaly were noted on chest X-ray ([Figure 1A](#fig-001){ref-type="fig"}). Pneumonia was diagnosed by the chest specialist first in our out-patient department, and the patient was transferred to the emergency department (ED) due to the diagnosis of pneumonia and severe dyspnea. Thoracentesis, done in ED, revealed a transudate as the level of total protein and lactate dehydrogenase (LDH) of the pleural fluid were 2.800 mg/dL and 79 mg/dL, respectively, while serum protein was 7.700 mg/dL and serum LDH was 190 mg/dL.

![Image studies of the patient. **(A)** A chest X-ray; **(B)** a CT scan of the thorax showing thickened pericardium with areas of calcification, and bilateral pleural effusions.](1757-1626-0002-0000007010-001){#fig-001}

Chest computed tomography scan also revealed thickened pericardium, up to 3 mm in diameter, minimal amount of pericardial effusion, a patchy fibrotic infiltration with bronchiectasis over the right upper lung, irregular thickening of the right intermediate bronchus, and obstruction of the right middle lung bronchus with consolidation and atelectasis of right middle lobe ([Figure 1B](#fig-001){ref-type="fig"}). There were several lymph nodes, up to 2.2 cm in size, in right paratracheal, pretracheal, subcarinal and left prevascular areas.

After treatment with diuretics, the peripheral edema improved significantly, but the patient still complained of severe dyspnea on exertion during the hospitalization. Echocardiograms showed thickened pericardium, especially over the right atrium, and small amount of pericardial effusion. The left ventricular wall motion was normal. However, there were limited right atrial wall motion and distended inferior vena cava with blunted respiratory variation. Under the impression of right heart failure due to constrictive pericarditis, the patient underwent cardiac catheterization. The hemodynamic studies ([Figure 2A](#fig-002){ref-type="fig"},[2B](#fig-002){ref-type="fig"}, and [2C](#fig-002){ref-type="fig"}) showed right atrium pressure 24/22 mmHg, pulmonary capillary wedge pressure 23 mmHg, prominent *x* and *y* descent in right atrial pressure tracings, dip-and-plateau pattern in the right ventricular diastolic pressure tracings. There was equalization of the end-diastolic pressures between right and left ventricles (24 mmHg).

![Pressure tracing of right-sided heart catheterization. **(A)** Right atrial pressure tracing; **(B)** right ventricular pressure; **(C)** simultaneous ventricular pressure tracing.](1757-1626-0002-0000007010-002){#fig-002}

Because of the diagnosis of constrictive pericarditis complicated with right heart failure, surgical operation for pericardial stripping was performed. Operative findings included markedly thickened pericardium and enlarged mediastinal lymph nodes. The postoperative course was uneventful with improvement of heart function. Pathology of the removed pericardium showed obvious granulomatous changes with caseous necrosis.

Only one sample of sputum specimen was collected on the operation day with vigorous humidifier using normal saline for several days, which was positive for acid-fast stain. The sputum culture gave positive result of *Mycobacterium tuberculosis* four weeks later. The patient was put on quadruple anti-tuberculosis chemotherapy and remains free from symptoms of heart failure.

Discussion {#s03}
==========

Persistent tuberculous pericarditis will lead to pericardial constriction due to chronic granulomatous inflammation of the pericardium with subsequent deposition of fibrinous strands, demonstrable on echocardiography \[[@bib-008]\]. Use of corticosteroid as an adjuvant therapy has been recommended for patients with tuberculous pericarditis and in the presence of large amount of pericardial or pleural effusion to suppress inflammation and reduce effusion. However, corticosteroids may aggravate the immunity of a compromised host, especially in the elderly \[[@bib-004],[@bib-009],[@bib-010]\]. Thus, the benefit of corticosteroids as adjuvant therapy in tuberculous pericarditis remains uncertain. Corticosteroids were not used in this patient, because only a small amount of pericardial effusion was detected by echocardiography initially and during follow-up period after operation. Moreover, anti-tuberculosis chemotherapy is still the cornerstone of the treatment for tuberculous pericarditis. In the endemic area, six-month anti-tuberculosis chemotherapy is recommended. The initial phase should consist of 2 months of isoniazid, rifampicin, pyrazinamide, and ethambutol. The preferred continuation phase consists of isoniazid and rifampicin given for 4 months \[[@bib-011]\].

In the chronic stage of tuberculous constrictive pericarditis, pericardial decortication with wide resection of both the visceral and the parietal pericardium, remains the definitive treatment \[[@bib-002]\]. However, there are no clear-cut determinants for surgical intervention when managed at the early stage. Yang et al. once reported that decision largely depended on the clinical symptoms of cardiac temponade, progression of heart failure, and constriction that lead to jugular vein engrossment \[[@bib-012]\]. They highlighted the importance of pursuing early pericardiectomy, rather than pericardiocentesis and window placement, to achieve sustained relief of symptoms in patients with advanced stage disease.

The diagnosis of tuberculous constrictive pericarditis in the current patient was confirmed by pathological findings. The patient did not suffer from any airway symptoms, even though atypical, for pulmonary tuberculosis, but was later verified by a positive sputum acid-fast stain and culture of *Mycobacterium tuberculosis*. It was not uncommon to see patients with tuberculous pericarditis, either effusive or constrictive, especially in endemic area, but our past experiences were that tuberculous constrictive pericarditis occurred much later after active tuberculous pulmonary infection or ineffective therapy of the pulmonary infection. There was no reported case of tuberculous constrictive pericarditis with concurrent active pulmonary tuberculosis. Our case is a constant reminder that active *Mycobacterium tuberculosis* infection does present itself with uncommon presentations.

Conclusion {#s04}
==========

Rapid diagnosis and treatment of constrictive pericarditis are crucial to reduce mortality. In some endemic areas, *Mycobacterium tuberculosis* infection should be taken into consideration during diagnostic evaluations for constrictive pericarditis. Surgical intervention is still the treatment of choice when the patient has the symptoms or signs of pericardial constriction and right heart failure.

Consent
=======

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

Competing Interests
===================

The authors declare that they have no competing interests.

Authors\' contributions
=======================

YWL was in charge of the patient, followed up the case and wrote the initial manuscript. HRT, and WHL contributed to the clinical work-up of the patient, including echocardiography and cardiac catheterization study. LJL and JHC carried out a review of the manuscript and made the final changes before submission.

ED

:   emergency department

LDH

:   lactate dehydrogenase