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 {#sec1-1}
============

Sternal bone marrow biopsy belongs to invasive diagnostic methods for differential diagnosis of whole spectrum of hematological diseases. As an invasive procedure, minor and major complications are subscribed in literature. Local complications (bleeding and infection from puncture site) are considered as minor ones. Major ones are due to improper technique or instrument usage and are as follows: manubrio-sternal dehiscence, sternal fracture, pneumopericardium, pneumotorax and biopsy needle breakage. Life threatening complications are because of pericardial tamponade caused by ascending aorta or right ventricle injury. We are subscribing such an injury below.

Case Report {#sec1-2}
===========

An 80-year-old man was brought to the regional hospital because of unclear abdominal pain, diarrhea and concomitant dehydration. He was admitted with diagnosis of pancreatic irritation and acute enteritis. Later, on the basis of laboratory examination of anemia (Ery 3.77×10^12^L, Hb 112 g/L, Hct 0.35) and thrombocytopenia (72×10^9^L), sternal bone marrow aspiration biopsy was performed. Approximately 45 minutes after the procedure the patient was complaining about general weakness and backache. Echocardiography examination showed pericardial effusion. Later, computer tomography scan excluded suspected ascending aortic dissection. Because of slowly ongoing hemodynamic stability deterioration, the patient was transported to cardiac surgical facility. Transoesophageal echocardiography confirmed pericardial tamponade with right atrium and ventricle compression and dyskinesis (Figure 1A). Immediate surgery was indicated.

Before surgical field draping off, puncture site on sternum was clearly visible (Figure 1B). After midline sternotomy, blood effusion in upper mediastinal tissue was found. When pericardial sac was opened, approximately 300 mL of blood were evacuated and hemodynamic stability was immediately achieved. Stab injury was found on the ascending aorta (Figure 1C). This location was sutured with pericardial pledgets. During postoperative course rehydration and short-time full parenteral nutrition was necessary. Overall state of health gradually improved and the patient was transferred back to regional hospital on 7^th^ post-operative day for further rehabilitation.

Discussion {#sec1-3}
==========

Bone marrow examination is used in the diagnosis of a number of hematological conditions. Aspiration may be done at several sites, but sternum is supposed to be the easiest site from which to obtain the most cellular marrow.[@ref1]

Heart injury with pericardial tamponade due to sternal puncture bone marrow biopsy has been rarely subscribed in literature. In 2003 issue of British Journal of Haematology,[@ref2] group of 54,890 sternal bone marrow biopsies were analyzed. Overall complications were found in 26 cases, bleeding in 14. No case of heart or aortic injury was observed. Authors from Denmark are on the contrary more cautious about heart injury.[@ref3] They have studied 34 sternal aspiration death-complication cases published and have identified performing physician lack of experience and wrong location of puncture site as a cause of trouble. German authors have published five cases of periprocedural right ventricle injury where one patient only was saved by emergent surgery.[@ref4] Sternal biopsy peri-procedural death was studied by American authors also. As a main cause of injury they have observed incorrect biopsy needle length according to sternal bone width.[@ref5] These studies are 10-30 years old and probable reason for late diagnosis of pericardial tamponade was lack of bedside echocardiography examination.

Occasional case reports of sternal biopsy heart injuries were published recently.^[@ref6],[@ref7]^ They are very rare (approx. 0.8% of all sternal biopsies performed). Adequate diagnostic echocardiography and timely cardiac surgery plays principal role in death complication prevention.[@ref8] Midline sternotomy and direct suture of injury site is a principle of successful surgical treatment.[@ref9]

Conclusions {#sec1-4}
===========

According to aforementioned studies, case reports and our clinical practice, several essential suggestions for sternal bone marrow biopsy arise: i) proper indication, clinical benefit must always outweigh potential risks; ii) experience of performing physician; iii) proper biopsy needle and its length; iv) site of puncture, medial part of sternal manubrium at the level of first intercostal space (should never be performed lower); v) follow up of the patient and timely echocardiography examination in case of any clinical status uncertainty; vi) in case of hemopericardium, fast cardiac surgery is indicated.

![A) Computed tomography scan. RA, right atrium; RV, right ventricle; LA, left atrium; LV, left ventricle; asterisk, pericardial effusion. B) Site of bone marrow biopsy puncture (encircled). C) Site of ascending aorta stab injury (showed by forceps).](hr-2013-3-e13-g001){#fig001}

[^1]: Contributions: the authors contributed equally.

[^2]: Conflict of interests: the authors declare no potential conflict of interests.