Cauliflower is trendy. It's become the hip, harlem shakin', Sriracha loving, Ray-Ban wearing vegetable of 2013. It's hot on demand and is quickly sneaking its way onto restaurant menus nationwide. Can't say I predicted that.
I could've predicted the past year's kale boom, the one that's quietly beginning to slow. Leafy, vibrant greens packed with nutrients – it was only a matter of time before they shifted beyond garnish status on the plate. This whole cauliflower craze though, it really snuck up on me. I definitely didn't see the day coming where cauliflower "steak" would push beef aside and become the highlight of a menu (at $34 a plate)! I could certainly argue with that price, but cauliflower shining across menus is fine by me.
Cauliflower doesn't make my grocery list all that often, but I admit, its crowns have been the favored ones ever since I was kid. My mom would often steam it up alongside broccoli, the green monster I'd grimace at after every bite. For the cauliflower, however, there was never any kind of the "you won't get dessert if you don't eat…" convincing needed. Today, I probably eat more of the green crowns than the white, but again I admit, cauliflower is still the favored one.
Its relatively neutral flavor makes it great for dishes like this (and apparently pizza crust too!). Here, cauliflower is paired with a slightly nutty millet, and then whipped up in a food processor. The result is a creamy, mashed potato-like texture yielded without any butter or cream needed. In fact, you could call this a no-fat version of mashed potatoes, although with the caraway seeds, it'll bring just a tad more complexity to the table. Feel free to skip the seeds altogether if you're looking for a neutral side or straight-up mashed potato replacement. However, I find the caraway to really add a nice, unique element you seldom find outside of rye bread.
I served this up with a batch of sautéed baby portabella mushrooms and garlic. To do the same, simply slice up 8 oz. baby portabellas along with a couple of garlic cloves. Saute in a little olive oil, deglazing the pan with a splash of balsamic vinegar, and seasoning with salt and pepper. Feel free to add in thyme or other herbs, or keep it simple and let the millet mash speak for itself. The mushrooms will add a nice depth of texture to the velvety smooth cauliflower.
In a large saucepan, heat 1/4 cup water. Add onions and saute for approx. 5 minutes, or until almost translucent. Add remaining 3 cups of water and salt and bring to boil. Add millet and cauliflower, and return to a boil.
Cover, and then reduce heat to a simmer. Cook for 35-40 minutes, or until all water is absorbed.
Transfer to a food processor (can substitute with a blender if needed, but food processor works best), and process until smooth and creamy. Stir in caraway seeds, and adjust salt and pepper, to taste.
*I served this up with balsamic glazed portabella mushrooms to add a bit of texture to the bowl. See last paragraph above for loose instructions.
Spring Asparagus Pesto I'm in Paris!
I would not have predicted a cauliflower resurgence either but here we are! crazy times.
These pseudo mashed potatoes sound awesome! The caraway seasoning is intriguing me..
Great recipe!! I need to use millet more often! Thanks also for linking to my cauliflower recipe. Cauliflower is such a versatile veggie!!


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AHEIA - Providing leadership to support and strengthen Australia's trade in horticultural produce.
Australian grapes grow in Korea
Export volumes of Australian table grapes have nearly quadrupled to Korea following tariff-free access.
In 2018 the Taste Australia campaign was brought to Korea to introduce Australia's premium grapes to Korean consumers.
Initially, the campaign was run and grapes stocked exclusively, at Hyundai Department Stores, but this year export volumes have increased and Korean retailers Emart and Shinsegae Department Store have joined Hyundai as stockists.
Grapes can be purchased at all Emart outlets, and selected Hyundai and Shinsegae stores, as well as a number of franchise fruit shops and wholesale markets. Samples of table grapes were handed out between 28 March and 14 April to consumers in-store covering a range of different varieties.
In 2018 the import duty for Australian table grapes was also eliminated under the Korea-Australia Free Trade Agreement.
Australia's table grape export season runs from January to May, and in the year ending June 2018, export volumes to Korea had almost quadrupled, up 379 per cent; albeit, from a small base, and in line with eliminations of the tariff, which reduced from 45 per cent to 6 per cent in 2017.
Since 2017, Australian table grapes have been promoted in the Korean market under a new brand name, Tams Gold. The name is a combination of the word 'tams-rudba', which Austrade says translates to 'attractive, nice, ripe and delicious looking', and the word gold which symbolises the golden/green colour of grapes.
At the time of the re-brand, Australian ambassador to Korea, James Choi, said the aim of the branding was to help assist Korean importers to satisfy the demand for quality grapes in Korea.
Joon Choi of major importer Soo Il Commerce said in mid-March he was gearing up for an aggressive approach toward grape promotions and has noted growth in the category due to increased volumes from the US.
Choi also said a range of new grape varieties entering Korea has peaked consumer interest.
This article was originally published in the June 2019 edition of Asiafruit Magazine
http://www.fruitnet.com/asiafruit
Author: Camellia Aebischer
"This project has been funded by the Australian Trade Commission as a part of the Asian Business Engagement (ABE) grant program and is supported by Trade and Investment Queensland and the Department of Agriculture and Fisheries Queensland."
Australian Horticultural Exporters' Association.

redpajama_set_name: RedPajamaCommonCrawl


When learning about SEO, you have probably read that you should only use www or non-www and only http or https. This begs the question: What does "only" even mean? Does it mean in all your blogs and PR events you must link consistently to https://www.example.com or is a forward from http://example.com to https://www.example.com good enough? My research for this suggests that a forward is enough and you do not need to worry, as long as you register all the versions of your site in the Google Search Console.
Nowadays if you have a somewhat potent webapp, you probably need users to login and therefore you need SSL (https). Whether you use www or non-www doesn't matter as long as you are consistent. Quora.com redirects to www and stackoverflow redirects to non-www, so you have examples of two sites that are good at SEO with different settings.
while the redirects non-www to www and http to https happen on the server. Here is an example for how to redirect from http to https using nginx.


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text:
package org.orekit.estimation.measurements.gnss;

import java.util.SortedSet;

import org.hipparchus.geometry.euclidean.threed.Vector3D;
import org.hipparchus.util.FastMath;
import org.junit.After;
import org.junit.Assert;
import org.junit.Before;
import org.junit.Test;
import org.orekit.Utils;
import org.orekit.attitudes.AttitudeProvider;
import org.orekit.bodies.CelestialBodyFactory;
import org.orekit.bodies.GeodeticPoint;
import org.orekit.bodies.OneAxisEllipsoid;
import org.orekit.estimation.measurements.EstimatedMeasurement;
import org.orekit.estimation.measurements.GroundStation;
import org.orekit.estimation.measurements.ObservableSatellite;
import org.orekit.estimation.measurements.ObservedMeasurement;
import org.orekit.estimation.measurements.generation.EventBasedScheduler;
import org.orekit.estimation.measurements.generation.Generator;
import org.orekit.estimation.measurements.generation.SignSemantic;
import org.orekit.frames.FramesFactory;
import org.orekit.frames.TopocentricFrame;
import org.orekit.gnss.Frequency;
import org.orekit.gnss.SatelliteSystem;
import org.orekit.gnss.attitude.GPSBlockIIA;
import org.orekit.gnss.attitude.GPSBlockIIR;
import org.orekit.orbits.CartesianOrbit;
import org.orekit.orbits.Orbit;
import org.orekit.propagation.Propagator;
import org.orekit.propagation.SpacecraftState;
import org.orekit.propagation.analytical.KeplerianPropagator;
import org.orekit.propagation.events.ElevationDetector;
import org.orekit.propagation.events.handlers.ContinueOnEvent;
import org.orekit.time.AbsoluteDate;
import org.orekit.time.FixedStepSelector;
import org.orekit.time.GNSSDate;
import org.orekit.time.TimeScalesFactory;
import org.orekit.utils.Constants;
import org.orekit.utils.IERSConventions;
import org.orekit.utils.TimeStampedPVCoordinates;

public class WindUpTest {

    @Test
    public void testYawSteering() {
        // this test corresponds to a classical yaw steering attitude far from turns
        // where Sun remains largely below orbital plane during the turn (β is about -18.8°)
        // in this case, yaw does not evolve a lot, so wind-up changes only about 0.024 cycle
        doTest(new CartesianOrbit(new TimeStampedPVCoordinates(new GNSSDate(1206, 307052670.0, SatelliteSystem.GPS).getDate(),
                                                               new Vector3D( 8759594.455119, 12170903.262908, 21973798.932235),
                                                               new Vector3D(-2957.570165356,  2478.252315039,  -263.042027935)),
                                  FramesFactory.getGCRF(),
                                  Constants.EIGEN5C_EARTH_MU),
               new GPSBlockIIA(GPSBlockIIA.getDefaultYawRate(17), GPSBlockIIA.DEFAULT_YAW_BIAS,
                               AbsoluteDate.PAST_INFINITY, AbsoluteDate.FUTURE_INFINITY,
                               CelestialBodyFactory.getSun(), FramesFactory.getGCRF()),
               SatelliteSystem.GPS, 17,
               new GroundStation(new TopocentricFrame(earth,
                                                      new GeodeticPoint(FastMath.toRadians(55.0 + ( 1.0 + 10.0 / 60.0) / 60.0),
                                                                        FastMath.toRadians(82.0 + (55.0 + 22.0 / 60.0) / 60.0),
                                                                        160.0),
                                                      "Новосибирск")),
               0.476338, 0.500405);
    }

    @Test
    public void testMidnightTurn() {
        // this test corresponds to a Block II-A midnight turn (prn = 07, satellite G37)
        // where Sun crosses the orbital plane during the turn (β increases from negative to positive values)
        // this very special case seems to trigger a possible bug in Block IIA attitude model.
        // The spacecraft starts its turn at about 0.1272°/s and the Sun changes
        // side, so the satellites keeps turning for about 70 minutes, completing one turn and an half
        // instead of only one half of a turn. One turn and an half seems unrealistic.
        // The wind-up effect changes therefore almost linearly by about 1.5 cycle
        doTest(new CartesianOrbit(new TimeStampedPVCoordinates(new GNSSDate(1218, 287890543.0, SatelliteSystem.GPS).getDate(),
                                                               new Vector3D(-17920092.444521, -11889104.443797, -15318905.173501),
                                                               new Vector3D(   231.983556337,  -3232.849996931,   2163.378049467)),
                                  FramesFactory.getGCRF(),
                                  Constants.EIGEN5C_EARTH_MU),
               new GPSBlockIIA(GPSBlockIIA.getDefaultYawRate(7), GPSBlockIIA.DEFAULT_YAW_BIAS,
                               AbsoluteDate.PAST_INFINITY, AbsoluteDate.FUTURE_INFINITY,
                               CelestialBodyFactory.getSun(), FramesFactory.getGCRF()),
               SatelliteSystem.GPS, 7,
               new GroundStation(new TopocentricFrame(earth,
                                                      new GeodeticPoint(FastMath.toRadians( -(25.0 + 4.0 / 60.0)),
                                                                        FastMath.toRadians(-(130.0 + 6.0 / 60.0)),
                                                                        0.0),
                                                      "Adamstown")),
               -1.853178, -0.361900);
    }

    @Test
    public void testNoonTurn() {
        // this test corresponds to a Block II-R noon turn (prn = 11, satellite G46)
        // where Sun remains slightly above orbital plane during the turn (β is about +1.5°)
        // this is a regular turn, corresponding to a half turn, so wind-up effect changes by about 0.5 cycle
        doTest(new CartesianOrbit(new TimeStampedPVCoordinates(new GNSSDate(1225, 509000063.0, SatelliteSystem.GPS).getDate(),
                                                               new Vector3D( 2297608.196826, 20928500.842189, 16246321.092008),
                                                               new Vector3D(-2810.598090399,  1819.511241767, -1939.009527296)),
                                  FramesFactory.getGCRF(),
                                  Constants.EIGEN5C_EARTH_MU),
               new GPSBlockIIR(GPSBlockIIR.DEFAULT_YAW_RATE,
                               AbsoluteDate.PAST_INFINITY, AbsoluteDate.FUTURE_INFINITY,
                               CelestialBodyFactory.getSun(), FramesFactory.getGCRF()),
               SatelliteSystem.GPS, 11,
               new GroundStation(new TopocentricFrame(earth,
                                                      new GeodeticPoint(FastMath.toRadians(   19.0 + (49.0 + 20.0 / 60.0) / 60.0),
                                                                        FastMath.toRadians(-(155.0 + (28.0 + 30.0 / 60.0) / 60.0)),
                                                                        4205.0),
                                                      "Mauna Kea")),
               -0.105573, 0.351411);
    }

    private void doTest(final Orbit orbit, final AttitudeProvider attitudeProvider,
                        final SatelliteSystem system, final int prn, final GroundStation station,
                        final double expectedMin, final double expectedMax) {

        // generate phase measurements from the ground station
        Generator           generator = new Generator();
        ObservableSatellite obsSat    = generator.addPropagator(new KeplerianPropagator(orbit, attitudeProvider));
        PhaseBuilder        builder   = new PhaseBuilder(null, station,
                                                         Frequency.G01.getWavelength(),
                                                         0.01 * Frequency.G01.getWavelength(),
                                                         1.0, obsSat);
        generator.addScheduler(new EventBasedScheduler<>(builder,
                                                         new FixedStepSelector(60.0, TimeScalesFactory.getUTC()),
                                                         generator.getPropagator(obsSat),
                                                         new ElevationDetector(station.getBaseFrame()).
                                                         withConstantElevation(FastMath.toRadians(5.0)).
                                                         withHandler(new ContinueOnEvent<>()),
                                                         SignSemantic.FEASIBLE_MEASUREMENT_WHEN_POSITIVE));
        SortedSet<ObservedMeasurement<?>> measurements = generator.generate(orbit.getDate(), orbit.getDate().shiftedBy(7200));
        Assert.assertEquals(120, measurements.size());

        WindUp windUp = new WindUpFactory().getWindUp(system, prn, station.getBaseFrame().getName());
        Propagator propagator = new KeplerianPropagator(orbit, attitudeProvider);
        double min = Double.POSITIVE_INFINITY;
        double max = Double.NEGATIVE_INFINITY;
        for (ObservedMeasurement<?> m : measurements) {
            Phase phase = (Phase) m;
            @SuppressWarnings("unchecked")
            EstimatedMeasurement<Phase> estimated = (EstimatedMeasurement<Phase>) m.estimate(0, 0, new SpacecraftState[] { propagator.propagate(phase.getDate()) });
            final double original = estimated.getEstimatedValue()[0];
            windUp.modify(estimated);
            final double modified = estimated.getEstimatedValue()[0];
            final double correction = modified - original;
            min = FastMath.min(min, correction);
            max = FastMath.max(max, correction);
        }
        Assert.assertEquals(expectedMin, min, 1.0e-5);
        Assert.assertEquals(expectedMax, max, 1.0e-5);

    }

    @Before
    public void setUp() {
        Utils.setDataRoot("regular-data");
        earth = new OneAxisEllipsoid(Constants.WGS84_EARTH_EQUATORIAL_RADIUS,
                                     Constants.WGS84_EARTH_FLATTENING,
                                     FramesFactory.getITRF(IERSConventions.IERS_2010, true));
    }

    @After
    public void tearDown() {
        earth = null;
    }

    private OneAxisEllipsoid earth;

}

redpajama_set_name: RedPajamaGithub


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text:
Home » Hepatitis C Prevalence Among Young Injectors in the EU
Hepatitis C Prevalence Among Young Injectors in the EU
(112)." data-share-imageurl="">
"Studies on young injectors (under 25) suggest a decline in prevalence of HCV at sub-national level in Slovakia, which may indicate falling transmission rates. Increases among young injecting drug users were reported in Bulgaria, Greece, Cyprus and Austria, although sample sizes in Greece, Cyprus and Austria were small. Increasing HCV prevalence among new injecting drug users (injecting for less than two years) was reported in Greece (nationally and in one region) (112). These studies, while difficult to interpret for methodological reasons, do illustrate that many injectors continue to contract the virus early in their injecting career, suggesting that the time window for initiating HCV prevention measures may often be small."
European Monitoring Centre for Drugs and Drug Addiction, "Annual report 2012: the state of the drugs problem in Europe" (Luxembourg: Publications Office of the European Union, November 2012), Catalog No. TDAC12001ENC, doi:10.2810/64775, p. 81.
http://www.emcdda.europa.eu/pu...


text:
Home Naslovna | News & Events
By U.S. Embassy in Podgorica | 17 April, 2015 | Topics: News
Embassy Joins Honoring International Roma Day (2015/4/8)
April 8, 2015 On April 8, U.S. Ambassador to Montenegro Margaret A. Uyehara made opening remarks at an award ceremony celebrating the best investigative journalism stories published in 2014 on the social integration of Roma in Montenegro. The ceremony was organized by the Montenegrin Ministry of Culture and Ministry for Protection of Human and Minority ...
By U.S. Embassy in Podgorica | 8 April, 2015 | Topics: News
U.S. Embassy Chargé d'Affaires Aliu to Open Conference on Administrative Law (2015/4/3)
April 6, 2015 The United States Embassy Podgorica, in cooperation with the Administrative Court and the Judicial Training Center (JTC), hosts a "Conference on the Use of Administrative Law in Investigating and Adjudicating Official Misconduct and Corruption Matters" in Bečići, Budva on April 6-7. U.S. Embassy Chargé d'Affaires Mr. B. Bix Aliu, President of the ...
28 + 1 Trees for NATO Day (2015/4/4)
April 4, 2015 Chargé d' Affaires B. Bix Aliu participated in planting 28 + 1 trees as a way to mark April 4, NATO Day. The first 28 trees symbolize the NATO member states, while the 29th tree symbolizes Montenegro as a future member state. The event was organized by the Atlantic Council of Montenegro ...
By U.S. Embassy in Podgorica | 3 April, 2015 | Topics: Press Releases


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text:
Q: A problem about the top and bottom margins of my chapters? I have a problem that the top margin of my chapters are large while the bottom margins are very small, here is the code I am using for my chapters:
\documentclass{book}
\usepackage[utf8]{inputenc}

\usepackage[a4paper, margin=1in]{geometry}

\usepackage[T1]{fontenc}
\usepackage{lmodern}

%\usepackage[ngerman]{babel}

\usepackage{tikz-cd}

\usepackage{mathtools}
\usepackage{commath}
\usepackage{bbm}
\usetikzlibrary{babel}
 \usetikzlibrary{shapes.geometric}
\usepackage{amsmath,amsfonts,amssymb}
\usepackage{graphicx}
\usepackage{setspace}
\usepackage{lipsum}
\usepackage{titlesec}
\newtheorem{theorem}{Theorem}
\newtheorem{prop}{Proposition}

\usepackage[nottoc]{tocbibind} % For adding List of Tables and List of Figures to Table of Contents
\usepackage[titles]{tocloft}

\makeatletter
\def\ps@headings{%
      \def\@oddfoot{\normalfont\hfil\thepage\hfil}%
      \def\@evenfoot{\normalfont\hfil\thepage\hfil}}
      \def\@evenhead{\hfil\slshape\leftmark}%
      \def\@oddhead{{\slshape\rightmark}\hfil%
      \let\@mkboth\markboth
    \def\chaptermark##1{%
      \markboth {\MakeUppercase{%
        \ifnum \c@secnumdepth >\m@ne
          \if@mainmatter
            \@chapapp\ \thechapter. \ %
          \fi
        \fi
        ##1}}{}}%
    \def\sectionmark##1{%
      \markright {\MakeUppercase{%
        \ifnum \c@secnumdepth >\z@
          \thesection. \ %
        \fi
        ##1}}}}
\makeatother
\pagestyle{headings}% apply new definitions

\begin{document}

\titleformat{\chapter}[display]
  {\normalfont\LARGE\bfseries}
  {\titleline{}\vspace{5pt}\titleline{}\vspace{1pt}%
  \MakeUppercase{\chaptertitlename} \thechapter}
  {1pc}
  {\titleline{}\vspace{0.5pc}}

\chapter{INTRODUCTION}
\section{MOTIVATION}
\end{document}

Is there any advice about that? I guess the problem in my code is in this part:
\titleformat{\chapter}[display]
  {\normalfont\LARGE\bfseries}
  {\titleline{}\vspace{5pt}\titleline{}\vspace{1pt}%
  \MakeUppercase{\chaptertitlename} \thechapter}
  {1pc}
  {\titleline{}\vspace{0.5pc}}

I need the top margin to be for example 1.5in and the bottom to be 1 in.

A: You want a reduced space between the top margin and the chapter title. In this case you just edit the \titleformat command as you mentioned in your question.
\titleformat{\chapter}[display]
  {\normalfont\LARGE\bfseries}
  {\titleline{}\vspace{1pt}\titleline{}\vspace{-0.9in}% The negative value here to move chapter title up
  \MakeUppercase{\chaptertitlename} \thechapter}
  {1pc}
  {\titleline{}\vspace{0.5pc}}

redpajama_set_name: RedPajamaStackExchange


text:
Congenital Hyperinsulinism and Evolution to Sulfonylurearesponsive Diabetes Later in Life due to a Novel Homozygous p.L171F ABCC8 Mutation
Emregül Işık
Hüseyin Demirbilek
Jayne A. Houghton
Sian Ellard
Sarah E. Flanagan
Khalid Hussain
Received Date: 02.03.2018 Accepted Date: 08.05.2018 J Clin Res Pediatr Endocrinol 2019;11(1):82-87 PMID: 29739729
Congenital hyperinsulinism (CHI) is the most common cause of persistent hypoglycemia in infants and children. Recessive inactivating mutations in the ABCC8 and KCNJ11 genes account for approximately 50% of all CHI cases. Hyperinsulinaemic hypoglycaemia in infancy and diabetes in later life have been reported in patients with HNF1A, HNF4A and ABCC8 mutations. Herein, we present a child who was diagnosed with CHI at birth, then developed diabetes mellitus at the age of nine years due to a novel homozygous missense, p.L171F (c.511C>T) mutation in exon 4 of ABCC8. The parents and one sibling were heterozygous carriers, whilst a younger sibling who had transient neonatal hypoglycemia was homozygous for the mutation. The mother and (maternal) uncle, who was also heterozygous for the mutation, developed diabetes within their third decade of life. The preliminary results of sulphonylurea (SU) treatment was suggestive of SU responsiveness. Patients with homozygous ABCC8 mutations can present with CHI in the newborn period, the hyperinsulinism can show variability in terms of clinical severity and age at presentation and can cause diabetes later in life. Patients with homozygous ABCC8 mutations who are managed medically should be followed long-term as they may be at increased risk of developing diabetes after many years.
Keywords: Congenital hyperinsulinism, MODY, ABCC8 mutation, children
Homozygous ABCC8 mutations cause severe, persistent, diffuse hyperinsulinemic hypoglycaemia (HH) which is usually diazoxide unresponsive and requires surgical therapy. In medically managed patients with congenital hyperinsulinism, disease symptoms become milder over time. HH in the neonatal period, and subsequent diabetes, have been reported in heterozygous mutations of HNF4A and HNF1A as well as heterozygous ABCC8 mutations.
We describe the first homozygous ABCC8 mutation with hyperinsulinemic hypoglycaemia (HH) in the neonatal period and its evolution to complete insulin deficient, sulphonylurea responsive diabetes mellitus. Findings from this present work, which show a broad clinical spectrum from asymptomatic to mild symptomatic hypoglycemia and severe hypoglycemia as well as insulin deficient diabetes mellitus in family members with identical mutation confirm the phenotypical variations in ABCC8 mutations. This present case report emphasizes the need for long-term follow up of patients with HH in the neonatal period due to ABCC8 mutations, particularly in those who have received medical therapy for risk of developing diabetes in later life.
Adenosine triphosphate (ATP)-sensitive potassium (KATP) channels play an essential role in the regulation of insulin secretion from the pancreatic beta-cell; the key mechanism maintaining the blood glucose level in a narrow range of 3.5-5.5 mmol/L (1,2,3). KATP channels are open at low glucose levels (1). Increased metabolism, resulting in an increased ATP/adenosine diphosphate ratio, leads to closure of the KATP channel, depolarisation of the beta cell membrane and subsequent calcium influx through voltage-gated calcium channels. This in turn leads to insulin secretion via the exocytosis of secretory granules (2,3). Dysfunction of the KATP channel can cause either congenital hyperinsulinism (CHI) or diabetes (neonatal or adult onset) (1,4,5,6,7,8,9). CHI occurs when KATP channels are absent on the cell membrane or when they remain closed despite low glucose levels. In contrast, diabetes occurs if KATP channels remain open despite high blood glucose concentrations and increased metabolism in the beta cell (1,4). Recessive inactivating mutations of the KATP channel genes (ABCC8 and KCNJ11) are the most common cause of severe, diazoxide unresponsive, diffuse CHI which usually requires pancreatectomy (1,10). Patients with dominant mutations of KATP channel genes, ABCC8 and KCNJ11, may cause variable phenotype ranging from asymptomatic macrosomia, mild diazoxide responsive CHI to severe persistent hyperinsulinaemic hypoglycaemia (HH) as well as diabetes mellitus in later life (7,8,9,11).
CHI within the neonatal period and evolution to diabetes later in life has been reported in individuals with heterozygous inactivating mutations in the hepatocyte nuclear factor 4A and 1A genes (HNF4A and HNF1A) (12,13,14) and dominant mutations in ABCC8 genes in a very limited number of cases (1,7,11,13,15,16,17,18,19,20,21).
To the best of our knowledge, CHI due to homozygous ABCC8 mutations and evolution to complete insulin deficient-diabetes later in life has not been reported. Herein, we present a patient with a novel, homozygous ABCC8 mutation who was diagnosed with CHI in the neonatal period and developed diabetes at the age of nine years.
A nine year-old Turkish boy (VI.2 in Figure 1) presented with abdominal pain and fever. He was diagnosed with perforated appendicitis and was referred to the endocrine clinic for coexisting hyperglycaemia (blood glucose level was 27.75 mmol/L). A detailed family history revealed the presence of diabetes in multiple members of the maternal family (see details on the pedigree and footnotes). Specifically, the patient's mother was on insulin therapy for diabetes mellitus which had been diagnosed during the first trimester of pregnancy, when she was 24 years of age. A maternal uncle was also affected. There was also a history of neonatal hypoglycaemia of varying duration and severity affecting two of the patient's siblings.
The patient was the first living child of the family and was born with a birth weight of 3750 grams (+6.6 SD) via caesarian section at a gestation age of 29 weeks. Parents were distantly related. He presented with a hypoglycaemic episode at postnatal day one (blood glucose was 1.33 mmol/L and simultaneous insulin level was 22.7 µIU/mL, C-peptide 5.42 ng/mL (0.9-7.1). A diagnosis of HH was considered and diazoxide was commenced. The patient developed pulmonary edema, which was considered likely to be a complication of treatment with diazoxide. Diazoxide was subsequently stopped and octreotide therapy was introduced. Hypoglycaemia remitted at the age of three months and the child remained free of hypoglycaemic episodes until nine years of age, when he was admitted to our hospital.
On admisson, the child was lethargic and had pale and grayish colour skin. His height was 140 cm [0.7 standard deviation score (SDS)], weight was 35 kg (0.8 SDS), and body mass index (BMI) 17.8 (0.7 SDS). Respiratory rate was 20 breaths/minute, heart rate was 72 beats/minute and blood pressure was 90/60 mmHg. There was abdominal distention, rigidity and rebound tenderness on physical examination. The patient underwent emergency appendectomy. During the post-operative period hyperglycaemia persisted and subcutaneous insulin therapy was introduced. Laboratory investigations revealed a blood glucose of 13.2 mmol/L with a simultaneous insulin of 8.82 µIU/mL (2.6-25), C-peptide: 1.28 ng/mL (0.9-7.1). Glycosylated haemoglobin A1c (HbA1c) was 9.1% (76 mmol/L). Islet cell, anti-insulin and anti-glutamic acid decarboxylase antibodies were negative. Over the following two months the insulin requirement gradually decreased until insulin treatment could be completely withdrawn. During the follow-up, HbA1c remained within the range of the high normal limits (6.2% to 6.4%) with dietary intervention and lifestyle changes. At the age of 11.5 years HbA1c was shown to be again significantly raised at 9.6% (81 mmol/L). At this time his weight was 46 kg (0.9 SDS), height was 152 cm (0.8 SDS) and BMI was 19.9 (0.9 SDS). The patient and family refused recommencement of insulin therapy. Subsequently, HbA1c increased to 11.4% (101 mmol/l) at the age of 12 years when an oral glucose tolerance test suggested insulin deficient-diabetes mellitus (Table 1).
Genomic DNA was extracted from peripheral leukocytes using standard procedures and the coding regions and intron/exon boundaries of the ABCC8, KCNJ11, HNF4A and HADH genes were amplified by polymerase chain reaction (primers available on request). Amplicons were sequenced using the BigDye Terminator Cycle Sequencing Kit V.3.1 (Applied Biosystems, Warrington, UK) according to manufacturer's instruction and reactions were analysed on an ABI 3730 Capillary sequencer (Applied Biosystems, Warrington, UK). Sequences were compared with the reference sequences (NM_001287174.1, NM_000525.3, NM_175914.4 and NM_005327.4) using Mutation Surveyor v5.0.1 software (SoftGenetics, State College, Pennsylvania, USA). The variant was classified using the American College of Medical Genetic and Genomics/Association for Molecular Pathology guidelines (22).
A written informed consent was obtained from the patients and/or their legal guardians.
The index patient (VI.2, see Figure 1) was found to be homozygous for a novel missense c.511C>T (p.L171F) variant in exon 4 of ABCC8 (Figure 2). The p.L171F variant affects a highly conserved amino acid and in silico analysis predicted the variant to be disease-causing (Alamut Visual V2.10 Software, Rouen, France). Mutation testing showed that the variant co-segregated with diabetes and hypoglycemia within the family, with an incomplete penetrance of heterozygous carriers
(Figure 1).
Treatment and Follow-up
Following detection of the ABCC8 mutation, a trial of sulphonylurea (SU) treatment was commenced in the index case and his mother, who had been on insulin therapy for 13 years in an outpatient setting (Table 2). The mother's daily insulin dose requirement was reduced by approximately 50% from the baseline at the first week of the SU therapy with improved blood glucose measurements. The index case also responded to SU therapy and even developed one hypoglycaemic episode following SU therapy. Although the SU doses were adjusted accordingly, the family avoided giving the glibenclamide regularly due to the severe hypoglycaemic episodes which had not been observed while he was on insulin therapy or during fasting.
Herein, we present a patient with a novel homozygous ABCC8 mutation who was diagnosed with HH in the neonatal period and diabetes at the age of nine years. Hyperglycemia was first recognized during acute appendicitis which suggested stress-induced hyperglycemia. However, the patient had persistent hyperglycemia which required insulin therapy, a history of HH and relatives with autoantibody-negative diabetes. These findings were suggestive of monogenic diabetes, which was confirmed by molecular genetics analysis.
Homozygous KATP channel gene mutations are the most common cause of severe, diazoxide unresponsive HH which often requires pancreatectomy (3,13). However, clinical heterogeneity is observed in patients with dominant ABCC8 mutations (9). Kapoor et al (23) reported a marked clinical heterogenity in siblings with identical mutations in ABCC8, ranging from asymptomatic hypoglycaemia to macrosomia, transient HH or severe HH and development of diabetes mellitus later in life. Besides, a heterogeneous nature is observed regarding severity and response to medical treatment and age of onset of symptoms (23).
Variations in the severity of HH and clinical course have also been reported in a mother and her daughter with a heterozygous E1506K mutation in ABCC8 (20). In this report the child had severe symptoms and hypoglycaemic convulsions at age three months while the mother had subtle symptoms of hypoglycaemia followed by gestational diabetes which persisted after delivery.
Similarly, a marked clinical heterogenity was also observed in this present family. While one of the homozygous siblings (VI.2, index case) had prolonged HH and required medical therapy, the other sibling with an identical homozygous mutation (VI.3) suffered from transient hypoglycemia in the first week of life which remitted within three months. Diabetes was observed in the heterozygous mother and a maternal uncle, but the father (V.1) who was also heterozygous for the ABCC8 mutation, had normal fasting plasma glucose and HbA1c levels. Unfortunately, the family refused performance of oral glucose tolerance test in the individuals who carried the mutation, but had not yet developed fasting hyperglycaemia or elevated HbA1c. We could also not perform genetic analysis in other relatives who also had diabetes with renal and ocular complications. We, therefore, were not able to confirm whether the diabetes in these additional family members was due to the ABCC8 mutation.
Indeed, the clinical course for patients with ABCC8 mutations is also substantially variable (1,7,13,15,16,17,18,19,20). Clinical features include hypoglycaemia within the neonatal period which remits over time, coexistence of hypoglycaemia and post-fed hyperglycaemic episodes, impaired fasting glucose or impaired glucose tolerance in response to a glucose load and in a few cases the development of diabetes (1,7,11,13,15,16,17,18,19,20). Regarding the type of mutation reported in ABCC8 which caused neonatal HH and diabetes later in life, only a few cases were reported to have a homozygous mutation (18), whilst the majority had heterozygous or compound heterozygous mutations (7,11,15,17,19,20).
Biallelic (either homozygous or compound heterozygous) ABCC8 mutations usually cause severe, diazoxide unresponsive HH which often requires surgical management (3). Therefore, the number of medically managed cases, particularly those with long-term follow-up, is very small. This limits our understanding of the underlying mechanisms and experience in the management of cases who develop hyperglycemia later in life. The data from the reported cases and experimental studies suggest that the key mechanisms are dysregulated insulin secretion, impaired first phase insulin secretion, delayed insulin response and b-cell apoptosis mediated via enhanced b-cell depolarisation, resulting in increased calcium ion entry into the cell (7,8,9,13,15,16,17,18,19,20,24,25,26).
Taking into account the previously reported cases, our patient is the only case with a homozygous ABCC8 mutation who presented with CHI (confirmed by clinical and biochemical evidence and mutation analysis) within the neonatal period which evolved into complete insulin deficient diabetes later in life. Therefore, this family provides novel insights into the clinical heterogeneity of CHI and later onset diabetes in patients with homozygous ABCC8 mutations.
Neonatal diabetes due to a dominant activating mutation of a KATP channel gene (KCNJ11 or ABCC8) is usually sulphonylurea responsive (27,28). We also performed a trial of SU therapy in the index case and his heterozygous mother who had insulin dependent diabetes. Preliminary results suggested a favorable SU responsiveness. Since SU drugs work by binding to the SUR1 subunit of the KATP channel, a positive response to SU therapy suggested that the presence of a homozygous mutation may not completely abolish the channel function.
In conclusion, we present the novel missense c.511C>T (p.L171F) ABCC8 mutation causing neonatal HH and SU-responsive diabetes mellitus later in life. There are, however, some limitations in interpreting the phenotype-genotype relationships observed in this family. Firstly, we were not able to analyse the mutation status of other family members with diabetes mellitus. Secondly, although clinical evidences and bioinformatic tools confirmed the pathogenicity of the novel mutation, functional analyses have not been undertaken to assess the role of the variant in vitro. These results highlight the need for the long-term follow up of a larger series of CHI patients with homozygous ABCC8 mutations who have been managed medically. In addition further evaluation of these variants, including functional analysis, to better understand the underlying molecular mechanism and phenotype-genotype relationships should be performed.
Informed Consent: A written informed consent was obtained from the patients and/or their legal guardians.
Peer-review: Externally peer-reviewed.
Surgical and Medical Practices: Emregül Işık, Hüseyin Demirbilek, Jayne A. Houghton, Concept: Emregül Işık, Hüseyin Demirbilek, Jayne A. Houghton, Sian Ellard, Sarah E. Flanagan, Khalid Hussain, Design: Emregül Işık, Hüseyin Demirbilek, Jayne A. Houghton, Sian Ellard, Sarah E. Flanagan, Khalid Hussain, Data Collection or Processing: Emregül Işık, Hüseyin Demirbilek, Jayne A. Houghton, Sian Ellard, Sarah E. Flanagan, Analysis or Interpretation: Emregül Işık, Hüseyin Demirbilek, Jayne A. Houghton, Sian Ellard, Sarah E. Flanagan, Khalid Hussain, Literature Search: Emregül Işık, Hüseyin Demirbilek, Jayne A. Houghton, Writing: Emregül Işık, Hüseyin Demirbilek, Jayne A. Houghton, Sian Ellard, Sarah E. Flanagan, Khalid Hussain.
Financial Disclosure: The authors declared that this study received no financial support.
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Congenital hyperinsulinism MODY ABCC8 mutation children


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