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This, in turn, stimulates downstream signaling elements dependent on both protein kinase A (PKA) and exchange protein directly activated by cAMP (EPAC) activation, which triggers the opening of voltage-dependent calcium channels (VDCCs), resulting in insulin exocytosis [24, 25]

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Purposive sampling was done where an independent consultant not related to the study selected the patients for each group and another consultant assessed the patients during follow-up

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