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This presents a potential limitation as it is possible that the data on VAS is not normally distributed in RCTs

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Alternative desensitization pathways include proteasome-mediated degradation of IRS-2 (63), direct dephosphorylation of IGF-1R by SHP-2 (64), its phosphorylation at serine residues by GSK-3 (65), or its inactivation by changes in the ganglioside composition of the cell membrane (66)