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
============

Elastoma was described by Weidman, Anderson, and Ayres in 1933, in a child who showed a disseminated form of the disease, hence the term juvenile elastoma.^[@r1],[@r2]^ Also known as elastic nevus, it is part of the connective tissue nevus group (CTNs) and is characterized clinically by the formation of yellow or normochromic papules and plaques. It is typically diagnosed in children, and may be congenital or acquired, developing in the second or third decade of life. Its formation is considered an embryological dysgenesis of the dermal mesenchyme, resulting in a more prominent disorder of elastic fibers.^[@r3]^

Elastoma may be clinically associated with osteopoikilosis, which characterizes the Buschke-Ollendorff syndrome (BOS), an autosomal dominant inheritance. However, sporadic forms, unassociated with extracutaneous manifestations, have also been reported.^[@r4]^

Differential diagnosis includes other CTNs, smooth muscle hamartoma, elastofibroma, elastic pseudoxanthoma, and elastosis perforans serpiginosa.^[@r5]^

This report aims to clinically demonstrate an unusual dermatosis, and the relevance of detailed histopathology for definitive diagnosis.

CASE REPORT
===========

A 7-year-old male patient with phototype II, was brought to medical consultation by his mother, who reported the emergence of asymptomatic lesions at the age of two in the lower back, where they remained unchanged during the first three years. Two years before the consultation, the number of injuries on the lower back increased, and new lesions appeared on his lower limbs and abdomen. Dermatological examination showed normochromic oval plaques, some of which yellow, with various shapes and sizes (1 cm -10cm), spread on his lower back, anterior and lateral thigh, anterior legs, and abdomen ([Figures 1](#f1){ref-type="fig"}-[3](#f3){ref-type="fig"}). The patient underwent biopsy; histopathological examination with hematoxylin and eosin staining showed an increase in the spaces between collagen fibers in the dermis ([Figure 4](#f4){ref-type="fig"}). Verhoeff\'s stain revealed morphological alterations in the elastic fibers, which had fragmented (elastolysis and elastorrhexis), some of them with coarser and more irregular shape than usual ([Figures 5](#f5){ref-type="fig"} and [6](#f6){ref-type="fig"}). Given the histopathological analysis, we made a clinical diagnosis of elastoma. The patient underwent radiological investigation, which was negative for bone abnormalities. The parents denied the presence of similar skin and bone changes in his family history. The patient is in outpatient follow-up and has shown the same number of lesions to date.

Figure 1Slightly yellowish plaques on the lower back

Figure 2Normochromic papules and plaques on the right thigh

Figure 3Normochromic papules and plaques on the abdomen (most recent lesions)

Figure 4Increased spaces between the collagen fibers in the dermis (400x hematoxylin & eosin)

Figure 5Staining of elastic fibers showing changes mainly in the middle and deep reticular dermis (100x Verhoeff)

Figure 6Irregular-shaped, fragmented elastic fibers (400x Verhoeff)

DISCUSSION
==========

CTNs are hamartomas characterized by an imbalance in the amount and distribution of collagen, elastin, and proteoglycans in the dermis.^[@r6]^

McCuaig et al. found 114 CTN cases from 1980 to 2008, 25 of which were classified as elastoma. Two of them were considered family-related, and six were caused by BOS; the remaining cases were esporadic.^[@r7]^

BOS is characterized by the presence of CTN and osteopoikilosis. Two forms of this syndrome are clinically described.^[@r8]^ The first, known as dermatofibrosis lenticularis disseminata, corresponds to a symmetrical and uniform rash of asymptomatic lichenoid papules, similar to the early phases of elastic pseudoxanthoma. The most common clinical form, in turn, shows larger, yellowish papules and nodes, sometimes grouped or coalesced, forming plaques. This rash is often asymmetric and can develop at any age, but most cases occur before puberty.

Osteopoikilosis is represented by multiple oval or rounded areas that appear opaque in bone radiography. They usually affect the bones of the carpus and tarsus, the long bones, and the pelvis. Therefore, radiological investigation should include anteroposterior X-ray of hands, wrists, feet, ankles, knees, and pelvis.

BOS is an autosomal dominant inheritance with variable expressivity, which justifies the ocurrence of both osteopoikilosis and elastoma in isolated cases. It has also been suggested that the occurrence of elastoma during adulthood might be caused by a degenerative process.^[@r9]^

In this case, the lesions are compatible with the most common clinical presentation of BOS, but the radiological study showed absence of bone changes in the child.

The alterations found in the histopathology of the elastoma are typical, regardless of whether the lesion is isolated or part of the BOS. While hematoxylin and eosin staining shows no abnormality, staining for elastic fibers show thick and tortuous bands between fairly normal collagen fibers in the reticular dermis. An increase in the number of elastic fibers around blood vessels in the papillary dermis may also be observed.^[@r9]^

It appears that the changes in the elastic fibers caused by the elastoma do not modify or increase the risk of morbidity and mortality of patients. Therefore, an accurate diagnosis of the lesions is important to reassure patients and their families, as well as to avoid unnecessary examinations and follow-up investigations. However, the skin lesions do require radiological investigation of the bones for osteopoikilosis.

Due to its rare ocurrence, there are no randomized studies assessing therapeutic possibilities for lesions diagnosed as elastoma. Therefore, there has been no known treatment to date.

Conflict of Interest: None

Financial Support: None

Work performed at the Pediatric Dermatology Department of the Escola Paulista de Medicina, Universidade Federal de São Paulo (EPM-Unifesp) - São Paulo (SP), Brazil.