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It enhances both synthesis and breakdown of extracellular matrix components, such as collagen, glycosaminoglycans (including dermatan and chondroitin sulfate), and decorin, and regulates metalloproteinases and their inhibitors (Pickart, Vasquez-Soltero, and Margolina 2015)

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It does not appear that ACOs necessarily need to progress along the glide path in their second agreement period as the participation trends suggest ACOs are ready to assume higher levels of risk and reward once they begin participating under a risk arrangement