Sepsis is a life-threatening organ dysfunction resulting from a dysregulated host response to infection, with its prevalence continuously rising in critical care units worldwide. ^[1] Despite advances in medical science, sepsis remains a significant global health challenge, contributing to high morbidity and mortality among intensive care unit (ICU) patients ^[2]. Early recognition and prompt management of sepsis are critical for improving outcomes, necessitating reliable biomarkers and scoring systems to assess the severity of the condition. This study focuses on correlating serum uric acid levels with the Quick Sequential Organ Failure Assessment (qSOFA) score in critically ill ICU patients with sepsis.

Sepsis involves a complex interplay of pro-inflammatory and anti- inflammatory responses, often leading to endothelial dysfunction, immune dysregulation, and tissue injury ^[3]. The clinical presentation of sepsis is heterogeneous, ranging from mild infection to septic shock and multi-organ failure ^[4]. Identifying reliable biomarkers is paramount for early diagnosis, risk stratification, and therapeutic monitoring in sepsis management.

Serum uric acid, a byproduct of purine metabolism, has emerged as a potential biomarker in critical illnesses, including sepsis. Elevated levels of uric acid have been associated with oxidative stress, inflammation, and endothelial dysfunction, all of which play a pivotal role in the pathogenesis of sepsis ^[5]. Furthermore, hyperuricemia has been linked to worse clinical outcomes in ICU patients, making it a promising candidate for risk stratification ^[6].

The qSOFA score was introduced by the Sepsis-3 guidelines as a simplified tool for identifying patients at risk of poor outcomes from sepsis outside the ICU ^[7]. It incorporates three parameters: altered mentation, systolic blood pressure ≤ 100 mmHg, and respiratory rate ≥ 22 breaths per minute. A score of ≥2 suggests a higher likelihood of sepsis-related mortality. ^[8] While qSOFA is practical and easy to use, its predictive accuracy is subject to ongoing scrutiny, highlighting the need for complementary biomarkers like serum uric acid to enhance its prognostic value. ^[9]

Uric acid, an endogenous antioxidant, plays a dual role in physiological and pathological states. At normal levels, it scavenges free radicals and prevents oxidative damage; however, in excess, uric acid exerts pro-oxidative and pro-inflammatory effects, contributing to endothelial dysfunction and tissue injury ^[10]. Hyperuricemia has been identified as a marker of poor prognosis in various conditions, including cardiovascular diseases, renal dysfunction, and critical illnesses ^[11].

In sepsis, elevated serum uric acid levels may reflect an intensified inflammatory response, cellular hypoxia, and impaired renal clearance. Studies have demonstrated an association between hyperuricemia and increased mortality in septic patients, but the correlation with scoring systems like qSOFA remains underexplored ^[12]. Investigating this relationship could provide a deeper understanding of sepsis pathophysiology and guide clinical decision-making.

The ability to predict outcomes in critically ill patients with sepsis is vital for optimizing treatment strategies and resource allocation. The qSOFA score, despite its simplicity, has limitations in sensitivity and specificity, necessitating adjunctive biomarkers for improved prognostication ^[13]. Serum uric acid, being readily measurable and cost-effective, offers potential as a complementary tool to qSOFA. By correlating serum uric acid levels with qSOFA scores, this study aims to enhance the utility of qSOFA in identifying high-risk sepsis patients.

Previous studies have highlighted the prognostic value of serum uric acid in various critical care settings, but its specific role in conjunction with qSOFA in septicpatients remains inadequately defined ^[14]. Addressing this gap could lead to better stratification of sepsis severity, aiding clinicians in early intervention and improving patient outcomes.

This study hypothesizes that elevated serum uric acid levels are significantly associated with higher qSOFA scores and worse clinical outcomes in critically ill septic patients. Furthermore, the inclusion of serum uric acid as a biomarker could enhance the predictive accuracy of the qSOFA score.

This research has significant implications for critical care medicine, particularly in resource-limited settings where advanced diagnostic tools may not be readily available. Serum uric acid is a simple and inexpensive biomarker, making it accessible in various healthcare settings. By elucidating its correlation with qSOFA scores, this study could contribute to the development of a more robust and cost- effective prognostic tool for sepsis management ^[15].

Additionally, understanding the pathophysiological role of uric acid in sepsis could pave the way for targeted therapies aimed at mitigating its detrimental effects. This study aligns with the broader goal of improving sepsis care and reducing its global burden through evidence-based strategies.

Sepsis remains a formidable challenge in critical care, necessitating innovative approaches for early recognition and risk stratification. The correlation between serum uric acid levels and qSOFA scores represents a promising avenue for enhancing sepsis prognostication. This study endeavours to bridge the knowledge gap by investigating the interplay between these two parameters, with the ultimate goal of improving outcomes for critically ill septic patients.

A Prospective observational study conducted at ICU of D Y Patil medical college hospital and research centre on Subjects admitted in ICU due to sepsis. For a duration of 2 Years. After an initial history and clinical examination Consent from all the participants will be taken to enroll in the study.

Based on a predefined approved proforma, the demographic data of the study participants completed. The blood samples taken for complete blood counts, serum procalcitonin, arterial blood gases, blood sugar levels, prothrombin time- international normalised ratio, liver function tests, renal function tests, serum lactate and serum uric acid levels on first day of ICU stay. Hyperuricemia is defined as the serum uric acid level ≥ 7 mg/dL in both males and females. Then we assess the qSOFA score of the patient on alternate days till ICU stay and correlate them for assessment of prognosis mortality and morbidity. A qSOFA score of more than or equal to 2 is significant and denotes in hospital mortality risk of more than 10%.  Inclusion criteria:  The inclusion criteria are patients’ age > 18 years with temp > 38 °C, leucocytosis or leucopenia and sepsis Exclusion Criteria Patients below 18yrs of age with sepsis.

The gender distribution among the study population. The study population shows a male predominance with 59.2% males and 40.8% females, suggesting either higher disease susceptibility in males.

Graph 1: Symptoms found among the study population.

Graph 1 shows the symptoms found among the study population. Abdominal distension is the most common presenting symptom (32.9%), followed by yellowish discoloration of eyes (jaundice) in 13 patients (17.1%), indicating significant hepatic involvement and possible portal hypertension; cardiovascular symptoms including breathlessness and chest pain each affected 6 patients (7.9%), while respiratory symptoms like cough with sputum affected 5 patients (6.6%), demonstrating multi-system involvement with predominant hepatic-gastrointestinal manifestations.

COPD-Chronic Obstructive Pulmonary Disease, CVA- Cerebro Vascular Accidents, DCLD – Decompensated Chronic Liver Disease, Diabetes Mellitus, HTN – Hypertension, IHD – Ischemic Heart Disease, TB- Tuberculosis

Graph 2: Co morbidities distributed among the study population

Graph 2 shows the co-morbidities distributed among the study population. Hypertension stands as the most prevalent comorbidity affecting 20 patients (26.3%), followed equally by diabetes mellitus and decompensated chronic liver disease each affecting 13 patients (17.1%), while tuberculosis affecting 7 patients (9.2%) and chronic obstructive pulmonary disease and ischemic heart disease each affects 6 patients (7.9%); notably, only 6 patients (7.9%) have no comorbidities, indicating this population carries a heavy burden of chronic diseases that likely complicate treatment outcomes and prognosis.

Table 1: Pattern of sleep among the study population

Table 1 shows the pattern of sleep among the study population.

Sleep disturbances affect 35 patients (46.1%) while 41 patients (53.9%) maintained normal sleep patterns, suggesting that while the majority preserve normal sleep pattern, a substantial minority experience sleep alteration that could indicate systemic illness severity, metabolic disturbances, psychological stress, or medication side effects related to their underlying condition.

Table 2: Addiction among the study population.

Table 2 shows the addiction among the study population. An exceptionally high addiction rate affected 56 patients (73.7%) with only 20 patients (26.3%) free from addiction, representing one of the most striking findings suggesting substance abuse as a major predisposing risk factor with complications directly related to liver disease, infections, and poor self-care.

Table 3: Temperature among the study population

Table 3 shows the temperature among the study population. The patient population is nearly equally divided with 36 patients (47.4%) presenting with fever and 40 patients (52.6%) remaining afebrile, suggesting variable inflammatory responses that could indicate different stages of disease progression, varying pathogen virulence, individual immune system responses, or the possibility that some patients may be

Graph 3: Mean demographics and clinical parameters of the study population.

Graph 3 shows the mean demographics and clinical parameters of the study population. The clinical assessment reveals a critically ill population with mean age 62.2 years (range 45-80) indicating primarily elderly patients who delayed treatment for an average of 5 days after symptom onset. Vital signs show concerning patterns including mean blood pressure 102/68 mmHg suggesting hypotension, elevated respiratory rate (28 breaths/min) indicating respiratory distress, and reduced oxygen saturation (91.8%) demonstrating respiratory compromise. Laboratory findings reveal severe abnormalities including markedly elevated white blood cell count (18,267) and procalcitonin (12.2 ng/mL) confirming severe bacterial infection, critically low platelet count (1.68) with elevated blood sugar (211.6 mg/dL) suggesting stress hyperglycaemia, significantly elevated creatinine (3.05 mg/dL) demonstrating acute kidney injury. There was elevated bilirubin (4.99 mg/dL) indicating the condition towards liver dysfunction, elevated lactate (3.22 mmol/L) indicating tissue hypoxia and poor perfusion, and mean qSOFA score of 2.25 indicating high risk for sepsis-related organ failure and mortality.

Table 4: Correlation among the q- SOFA score and the other biomarkers among the study population

Table 4 shows the Spearmans correlation analysis with a very strong positive correlation between q-SOFA scores and serum uric acid levels (Spearman’s ρ = 0.884, p < 0.001), as well as between q-SOFA scores and serum procalcitonin levels (ρ = 0.901, p < 0.001), indicating that both biomarkers increase significantly with higher q-SOFA scores. A strong correlation was also observed between uric acid and procalcitonin levels (ρ = 0.831, p < 0.001). In contrast, no significant correlation was found between q-SOFA scores and WBC count (ρ = 0.200, p = 0.083), or between WBC and the other biomarkers, suggesting WBC is not closely associated with disease severity in this sample.

The gender distribution in our study revealed a mild male predominance, with 45 of 76 participants (59.2%) being male and 31 (40.8%) females. This skewed ratio is consistent with several regional and international studies on sepsis and critical illness. In a prospective cohort study conducted by Mishra and Jatav (2022)^[41] at a tertiary Centre in Madhya Pradesh, 56.3% of the 80 enrolled sepsis patients were male, closely mirroring our demographic pattern. Similarly, Nadeem et al. (2021) ^[51], who studied 102 sepsis patients in Srinagar, reported a male proportion of 53.9%, reinforcing the trend of modest male predominance in Indian sepsis cohorts. Akbar et al. (2015), in a U.S.-based MICU study on hyperuricemia and sepsis outcomes, also documented a similar male distribution (57.6% male), suggesting that this demographic feature is consistent across healthcare systems.

These parallels suggest a globally observable pattern wherein males constitute a larger proportion of patients presenting with systemic illness or sepsis. While biological factors such as sex-linked immune modulation may play a role, this finding may also reflect behavioral patterns, with men potentially having higher exposure to infection risks, delayed health-seeking behavior, or increased rates of comorbidities. Importantly, none of the referenced studies including ours found gender to be a significant independent predictor of outcomes, such as mortality or need for organ support. For instance, Nadeem et al. ^[51] reported no statistically significant association between gender and in-hospital death (p = 0.542), and a similar non-significance was noted by Mishra and Jatav. ^[41]

The near-uniformity of male predominance across these studies enhances the external validity of our findings and underscores the need for equally vigilant screening and prognostic assessment in both sexes, despite minor demographic differences. Gender-balanced inclusion should continue to guide clinical research and resource allocation strategies.

Symptoms at Presentation to Hospital (Table 2)

The typical spectrum of sepsis-related presentations observed in Indian ICUs. For instance, the SEPSIS INDIA study by Todi et al (2024), a multicenter prospective registry of 1,172 ICU sepsis admissions, found that the most common sources were pulmonary and gastrointestinal, with a high proportion of patients presenting with abdominal symptoms and altered mentation. The mean SOFA score on admission was 6.7, and 36.3% overall mortality underscored the systemic burden of illness. Similarly, a South Indian ICU study by Garg et al. (2022)              documented respiratory distress, altered sensorium, and oliguria among the most common initial complaints in their cohort of 400 patients, where 69% were male, and pulmonary sepsis (e.g., cough, dyspnea) accounted for 46.3% of infections. Their study found significant associations between these symptoms and high SOFA scores, ICU mortality, and early deterioration, particularly in patients with renal dysfunction or hemodynamic instability.

Our observation of jaundice-like symptoms (17.1%) aligns with emerging recognition of hepatic involvement in sepsis, especially in tropical countries where infections like leptospirosis, dengue, and viral hepatitis may complicate systemic inflammation. Though cellulitis and other cutaneous signs were less frequent (3.9%), their presence often reflects localized infection or soft-tissue involvement, which may evolve into systemic sepsis.

The distribution of symptoms in our study highlights the multi-systemic and often non-specific nature of sepsis presentations, with abdominal and hepatic symptoms being particularly prevalent. The overlap with cardiovascular, respiratory, and renal symptoms further complicates triage, underscoring the importance of standardized early warning tools like qSOFA. Our findings also support the need for syndromic triage protocols in emergency settings, especially in endemic regions where systemic illness often masks underlying infection severity.

Comorbidities (Table 3)

Our findings are consistent with the South Indian ICU study by Garg et al.  (2022), where among 400 sepsis patients, hypertension (62%) and diabetes (51.3%) were the most frequent comorbidities. Their study also found that comorbidities such as renal dysfunction and higher baseline creatinine were significantly associated with 28-day mortality, particularly in those with elevated SOFA scores and early ICU deterioration. Likewise, the SEPSIS INDIA registry by Todi et al. (2024) found similar patterns, with comorbidity burden serving as a key driver of poor outcomes, especially in patients requiring vasopressor or ventilator support. ^[61]

While our study did not stratify outcomes by individual comorbidities, the presence of chronic liver disease, COPD, and tuberculosis in a notable proportion of patients may suggest an added layer of immunological and metabolic vulnerability that could influence sepsis progression. However, this hypothesis warrants targeted subgroup analysis in future studies.

Our data reinforce that comorbidities, particularly hypertension and diabetes, are common and clinically relevant in sepsis and systemic illness presentations. Their presence should prompt early screening for organ dysfunction, and careful hemodynamic and metabolic monitoring. Understanding patient comorbidity profiles remains essential for prognostication and tailoring individualized care strategies.

Sleep Status (Table 6)

Guo et al. (2024) ^[63] emphasized the bidirectional interplay between sepsis and sleep disorders, with an estimated 50% prevalence of atypical sleep architecture in septic patients. These alterations characterized by sleep fragmentation, reduced REM sleep, and circadian rhythm dysregulation were associated with impaired immune response, cytokine surge, and increased risk of multiorgan failure and mortality. Their findings affirm that sleep disturbance is not merely a consequence but potentially an early indicator and amplifier of sepsis pathophysiology.

Further support comes from Dong et al. (2023)^[64], who highlighted the persistence of sleep disorders in critically ill ICU patients. They identified poor sleep quality and frequent nighttime arousals as key contributors to post-ICU syndrome, and stressed the importance of both subjective (e.g., patient-reported) and objective (e.g., autography, EEG) evaluations of sleep in ICU care protocols.

Although our study did not formally use polysomnography or sleep scoring tools, the high prevalence of altered sleep in our cohort suggests early neurocognitive involvement, which aligns with findings by Bhudhrani et al. (2024)^[65] who reported altered mentation and neurologic symptoms in a significant proportion of ICU sepsis admissions in Gujarat.

Our findings underscore that altered sleep may serve as a surrogate marker of early neurologic dysfunction or cytokine-driven brain inflammation in systemic illness. Given its high prevalence and known prognostic implications, routine assessment of sleep quality should be integrated into initial sepsis screening. Future studies using validated sleep scales or EEG may provide deeper insights into its diagnostic and prognostic value. Appetite (Table 4)

Our findings are in line with a recent Indian ICU study by Kumar et al. (2024)^[66] which found that 56.9% of septic patients had hypoalbuminemia, a surrogate marker for poor nutritional status and reduced intake. Importantly, patients with hypoalbuminemia showed significantly higher mortality (29.3%) and increased vasopressor dependency (p = 0.029), reinforcing the prognostic role of malnutrition in sepsis outcomes.

In a broader clinical context, Zhou (2024)^[67] outlined the role of Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) as a post-sepsis phenotype marked by chronic anorexia, weight loss, and muscle wasting. The author emphasized how catabolic dominance and loss of appetite are tightly linked to poor prognosis and prolonged ICU stays. These mechanisms underscore the pathophysiological significance of appetite as a clinical marker not just a subjective symptom in sepsis care.

The nearly 45% prevalence of reduced appetite in our patients aligns with established clinical patterns and may signal a pro-inflammatory or catabolic state early in the disease course. In resource-limited settings, subjective symptoms like reduced appetite can serve as valuable adjuncts to prognostic scoring, especially where biochemical markers like albumin may not be immediately available. Early nutritional assessment and intervention may improve outcomes and should be integrated into sepsis protocols.

Addiction (Table 5)

Our findings are considerably higher than those reported in the hospital-based cross- sectional study by Rao et al. (2024) ^[68] where 37.6% of 290 medically ill inpatients reported lifetime substance use. In their study, tobacco (31.4%) and alcohol (23.8%) were the most common substances, and substance use was significantly associated with injury-related and circulatory system diseases, conditions frequently encountered in ICU admissions.

Supporting the critical care context, Qadri et al. (2024)^[69] conducted a prospective ICU study of 35 drug-abusing patients admitted for overdose (mostly heroin). They reported that 91.4% experienced respiratory failure, and 11.4% mortality was due to sepsis or multi-organ failure. Despite the relatively young mean age (29.1 years), the severity of organ dysfunction highlights the vulnerability of substance-using patients to systemic deterioration once hospitalized.

A broader view from Indian ICUs comes from Gopaldas et al. (2023)^[70], who noted widespread underreporting of alcohol use disorders (AUDs), often due to insurance-related non-disclosure or lack of formal screening. This discrepancy suggests that the true prevalence of addiction among hospitalized patients may be higher than reported, especially in the absence of dedicated psychiatric evaluation or screening tools.

The high addiction prevalence in our cohort may reflect both regional trends and the elevated vulnerability of substance users to sepsis, metabolic crisis, and delayed care-seeking. Given the well-documented link between substance use and poor ICU outcomes, integrating early addiction screening and psychiatric consultation into sepsis protocols may improve both immediate and long-term outcomes. Our findings also underscore the need for more structured documentation and stigma-free assessment of substance use in critical care settings.

Temperature (Table 6)

Similar trends have been observed in large Indian ICU cohorts. The SEPSIS INDIA registry by Todi et al. (2024) ^[61] noted that although fever was among the most common presenting signs, a substantial proportion of patients were afebrile, especially those with chronic comorbidities or late-stage presentation. Their findings emphasized the need for multi-parameter sepsis screening tools like qSOFA, as reliance on fever alone can miss high-risk patients.

In the study by Garg et al. (2022)^[62], a similar observation was made: fever was present in a little over half of the patients, and was not independently associated with mortality. Instead, variables like hypotension, altered sensorium, and elevated creatinine were stronger predictors of adverse outcomes. This further underscores the limited sensitivity of temperature alone in sepsis screening and triage.

International literature supports this trend. Studies have shown that up to 30– 50% of sepsis patients present afebrile, with such cases often associated with higher mortality, possibly due to delayed recognition and treatment initiation. Afebrile patients may also show blunted inflammatory responses, a marker of immune exhaustion or severe disease trajectory.

The fact that over half of our patients were afebrile reinforces that temperature alone is an insufficient screening tool for systemic illness. Clinicians should rely on composite clinical criteria (e.g., qSOFA, lactate, mental status) to identify high-risk patients, especially in older or comorbid populations. Early detection of sepsis requires a paradigm shift from fever-based heuristics to integrative, symptom-driven evaluation.

Mean Demographics and Clinical Parameters (Table 7)

Our study population had a mean age of 62.17 years, with symptoms persisting for an average of 7.7 days before presentation and treatment sought around day 5, indicating a delay in healthcare access. Such delays are often associated with advanced disease stage at presentation and increased risk of complications, as reported by Todi et al. (2024)^[61], where delayed presentation (>72 hours) was significantly linked to ICU mortality and vasopressor requirement.

The mean qSOFA score was 2.25, consistent with early risk stratification in sepsis. According to Mishra & Jatav (2022)^[41], qSOFA ≥2 was significantly associated with poor clinical outcomes and longer hospitalization in their sepsis cohort. A higher qSOFA score (3 in 65% of their patients) also predicted increased mortality and renal dysfunction.

Laboratory parameters reflected substantial metabolic and organ dysfunction. The mean serum procalcitonin (PCT) level was 12.21 ng/mL, markedly elevated and strongly indicative of bacterial sepsis. Akbar et al. (2015) and Nadeem et al. (2021) both reported PCT levels above 10 ng/mL as predictors of mortality and organ failure in ICU patients with sepsis. ^[52,51]

Similarly, mean serum uric acid was 8.3 mg/dL, above the 7 mg/dL risk threshold identified in Mishra & Jatav (2022)^[41] and Akbar et al. (2015)^[52]. Elevated uric acid was associated with longer hospital stay, higher qSOFA scores, and greater mortality, potentially due to its link with oxidative stress and impaired renal clearance in systemic inflammation.

Serum lactate averaged 3.22 mmol/L, again exceeding the sepsis severity threshold of 2.0 mmol/L. High lactate levels reflect tissue hypo perfusion and anaerobic metabolism, and were associated with ICU mortality in the SEPSIS INDIA registry and multiple global trials. Garg et al. (2022)^[62] also found lactate and serum creatinine to be independent predictors of mortality in their Indian ICU cohort. The mean arterial oxygen partial pressure (PaO₂) was 74.9 mmHg, close to the lower cutoff for adequate oxygenation, while mean Spot₂ was 91.8%, indicating mild hypoxia. Coupled with elevated respiratory rate (28.3/min) and creatinine (3.05 mg/dL), these findings reflect multi-systemic involvement. Nadeem et al. emphasized the prognostic weight of PaO₂ and creatinine as early indicators of impending organ failure^{. [51]}

The convergence of elevated qSOFA, uric acid, lactate, and procalcitonin in our cohort highlights a biochemical signature of high-risk sepsis, compounded by delayed treatment and multi-organ dysfunction. These markers align with national and international prognostic frameworks and underscore the need for rapid, multi- parameter assessment upon presentation, particularly in resource-limited settings. Implementing bundled sepsis care that includes PCT, qSOFA, and lactate may enhance early recognition, risk stratification, and survival outcomes.

Bolanaki et al. (2021) evaluated the diagnostic performance of procalcitonin (PCT) in emergency department patients with suspected sepsis and elevated q-SOFA scores. In their prospective multicenter study involving 742 patients, they found that PCT had a high diagnostic value for early identification of sepsis (AUC = 0.86), showing a significant correlation with q-SOFA scores. Their findings support the observed strong association between q-SOFA and procalcitonin levels ^[71].

Koch et al. (2019) conducted a multicenter cohort study examining the value of combining PCT with q-SOFA to improve mortality prediction in patients with suspected sepsis. They reported that adding PCT to the q-SOFA scoring system improved the sensitivity and net reclassification index, further validating the role of PCT as a valuable biomarker alongside q-SOFA ^[72].

Açık et al. (2025) studied the impact of hyperuricemia in critically ill elderly cancer patients with sepsis. They observed that patients with elevated serum uric acid levels also had significantly higher q-SOFA scores and procalcitonin levels. Their results align with the present study’s findings, reinforcing the strong correlation between uric acid and both q-SOFA and PCT ^[73].

Churpek et al. (2017) analyzed various predictors of clinical deterioration, including WBC count, in patients with suspected infection. They found that WBC had limited predictive power compared to other biomarkers like lactate and PCT, suggesting that WBC alone may not be a reliable marker for disease severity— supporting the weak correlations observed in this study between WBC and q-SOFA or PCT^[74].

The elevated mean values of qSOFA, serum procalcitonin, lactate, and uric acid markers in our cohort align with profiles seen in severe sepsis and were often accompanied by multi-organ dysfunction indicators like hypoxia, reduced urine output, and altered consciousness. Delayed presentation (nearly 5 days on average) further compounded risk, emphasizing the need for public health strategies that promote earlier healthcare access. Non-specific presentations, including afebrile states, appetite loss, and altered sleep, are common and should not delay sepsis evaluation. Clinical scoring systems like qSOFA, when paired with inexpensive biochemical markers such as uric acid or PCT, can enhance early risk identification and help prioritize patients for intensive monitoring or escalation.

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