TechnoSTAT Ltd (Israel) and Target Health Inc. (USA) Partner in EDC and the Paperless Clinical Trial
New York, NY, Ra’anana, Israel, 21 July, 2013 – Target Health Inc., and TechnoSTAT Ltd., are pleased to announce a strategic collaboration to provide high quality and competitively priced 21 CRF Part 11 compliant electronic data capture (EDC) and paperless clinical trial solutions to Israeli life science companies. TechnoStat will utilize Target e*Studio® to develop, deploy, and maintain clinical trial applications using Target e*CRF® for data collection. In addition to Target e*Studio, TechnoSTAT will also offer Target e*CTR®, which allows clinical study sites to perform direct data entry at the time of the office visit, thus eliminating/minimizing the need for paper source records. TechnoSTAT will also incorporate Target Document® as a solution to the eTrial Master File (eTMF); Target Encoder® for coding of adverse events, medications and medical histories using MedDRA and WHO Drug and other types of dictionaries, and; Target e*Pharmacovigilance™ which generates an FDA approved facsimile of MedWatch Form 3500A and the international CIOMS Form 1. Both forms can be used for regulatory submissions, with the ability to control the original and followup versions of the forms within the EDC application.
The partnership will provide US FDA regulatory services by Target Health to Israeli life sciences clients of TechnoSTAT, and to US-based life science companies, additional biostatistical consulting and programming services by TechnoSTAT. Both companies will also collaborate in the management and execution of clinical trials both in Israel and in the USA under common SOPs.
“We are very enthusiastic about expanding our existing market in Israel with TechnoSTAT and working closely with our colleagues at TechnoSTAT to assist them in becoming the leading provider of EDC and paperless clinical trial services in Israel.” comments Target Health’s President, Dr. Jules T. Mitchel. “With over 20 years of clinical trial and clinical trial information systems developed and implemented at Target Health, coupled with the in-depth experience of TechnoSTAT in clinical management, data management and biostatistics, this partnership is a natural,” Dr. Mitchel added.
“TechnoSTAT, in joining forces with Target Health, will bring to the Israeli Life Sciences Industry, a new level of sophistication consistent with Israel being known as the Startup Nation” explains Maya Talmon, CEO of TechnoSTAT. Ms. Talmon added that “It is clear that the paperless clinical trial is here to stay and collaborating with the Target Health team and their electronic toolbox, will allow us to be on that path.”
For more information about Target Health contact Warren Pearlson (212-681-2100 ext. 104). For additional information about software tools for paperless clinical trials, please also feel free to contact Dr. Jules T. Mitchel or Ms. Joyce Hays. The Target Health software tools are designed to partner with both CROs and Sponsors. Please visit the Target Health Website.
Body’s Response to Repetitive Laughter Is Similar to the Effect of Repetitive Exercise
A new study looks at the effect that mirthful laughter and distress have on modulating the key hormones that control appetite. (Credit: iStockphoto/Wouter Van Caspel)
Laughter is a highly complex process. Joyous or mirthful laughter is considered a positive stress (eustress) that involves complicated brain activities leading to a positive effect on 1) ___. Norman Cousins first suggested the idea that humor and the associated laughter can benefit a person’s health in the 1970s. His ground-breaking work, as a layperson diagnosed with an autoimmune disease, documented his use of laughter in treating himself — with medical approval and oversight — into remission. He published his personal research results in the New England Journal of Medicine and is considered one of the original architects of mind-body 2) ___.
Dr. Lee S. Berk, a preventive care specialist and psychoneuroimmunology researcher at Loma Linda University’s Schools of Allied Health (SAHP) and Medicine, and director of the molecular research lab at SAHP, and Dr. Stanley Tan have picked up where Cousins left off. Since the 1980s, they have been studying the human body’s response to mirthful laughter and have found that laughter helps optimize many of the functions of various body systems. Berk and his colleagues were the first to establish that laughter helps optimize the hormones in the 3) ___ system, including decreasing the levels of cortisol and epinephrine, which lead to stress reduction. They have also shown that laughter has a positive effect on modulating components of the immune system, including increased production of antibodies and activation of the body’s protective cells, including T-cells and especially Natural Killer cells’ killing activity of tumor cells.
Their studies have shown that repetitious “mirthful laughter,” which they call Laughercise©, causes the body to respond in a way similar to moderate physical exercise. Laughercise enhances your mood, decreases stress hormones, enhances immune activity, lowers bad cholesterol and systolic blood pressure, and raises good 4) ___ (HDL). As Berk explains, “We are finally starting to realize that our everyday behaviors and emotions are modulating our bodies in many ways.” His latest research expands the role of laughter even further.
A New Study: Humor versus Distress, Effect on Appetite Hormones
The study, presented at the Experimental Biology conference) recruited 14 healthy volunteers to examine the effects that eustress (mirthful 5) ___) and distress have on modulating the key hormones that control appetite. During the 3-week study, each subject was required to watch one 20-minute video at random that was either upsetting (distress) or humorous (eustress) in nature. The study was a cross-over design, meaning that the volunteers waited one week after watching the first video to eliminate its effect, then watched the opposite genre of video.
For a distressing video clip, the researchers had the volunteer subjects watch the tense first 20 minutes of the movie Saving Private Ryan. This highly emotional video clip is known to distress viewers substantially and equally. For the eustress video, each volunteer chose a 20-minute video clip from a variety of humorous options including stand-up comedians and movie comedies. Allowing the volunteers to “self-select” the eustress that most appealed to them guaranteed their maximum humor response. During the study, the researchers measured each subject’s blood 6) ___ and took blood samples immediately before and after watching the respective videos. Each blood sample was separated out into its components and the liquid serum was examined for the levels of two hormones involved in appetite, leptin and ghrelin, for each time point used in the study.
When the authors compared the hormone levels pre- and post-viewing, they found that the volunteers who watched the distressing video showed no statistically significant change in their 7) ___ hormone levels during the 20-minutes they spent watching the video. In contrast, the subjects who watched the humorous video had changes in blood pressure and also changes in the leptin and ghrelin levels. Specifically, the level of leptin decreased as the level of ghrelin increased, much like the acute effect of moderate physical exercise that is often associated with increased appetite. Berk explained that this research does not conclude that humor increases appetite. He stated that “The ultimate reality of this research is that laughter causes a wide variety of modulation and that the body’s response to repetitive laughter is similar to the effect of repetitive 8) ___. The value of the research is that it may provide for those who are health care providers with new insights and understandings, and thus further potential options for patients who cannot use physical activity to normalize or enhance their appetite.”
Appetite Loss may have a new Treatment Option
Many elderly patients often suffer from what is known as “wasting disease.” They become depressed and, combined with a lack of physical activity, lose their appetite and jeopardize their health and well-being. Based on Berk’s current research, these patients may be able to use Laughercise as an alternative, initially less strenuous, activity to regain their appetite. A similar loss of appetite is often seen in widowers, who typically suffer 9) ___ after the loss of a spouse. This often results in decreased immune-system function and subsequent illness in the surviving spouse. Chronic pain patients also suffer from appetite loss due to the chemical changes in their body that cause intolerable discomfort. While laughter may seem unimaginable in the face of deep depression or intense chronic pain, it may be an accessible alternative starting point for these patients to regain appetite and consequently, improve and enhance their recovery to health.
Berk’s current research expands the role of laughter on the human 10) ___ and whole-person care, but also complicates an already complicated emotion. He acknowledges, “I am more amazed by the interrelatedness of laughter and body responses with the more evidence and knowledge we collect. It’s fascinating that positive emotions resulting from behaviors such as music playing or singing, and now mirthful laughter, translate into so many types of [biological] mechanism optimizations. As the old biblical wisdom states, it may indeed be true that laughter is a good medicine.”
ANSWERS: 1) health; 2) medicine; 3) endocrine; 4) cholesterol; 5) laughter; 6) pressure; 7) appetite; 8) exercise; 9) depression; 10) body
Norman Cousins, Pioneer of Laughter-as-Medication (1915-1990)
The healing properties of laughter have been extolled since biblical times; in the book of Proverbs, you’ll find this quote: “A merry heart doeth good like a medicine.” When it comes to modern day laughter therapy, however, you’ll want to consider the book of Cousins. More precisely, the tome “Anatomy of an Illness (As Perceived by the Patient),” written by Norman Cousins in 1979.
When Cousins was diagnosed with ankylosing spondylitis, an incurable and fatal spinal column illness of unknown cause, he was given very slim odds of recovery. He was unable to move and in constant pain. However, in the midst of this dire situation, Cousins didn’t lose his sense of humor. He credits his recovery to a prescription of “Candid Camera” episodes, Marx Brothers movies and funny stories read by nurses. With 10 minutes of laughter, he wrote, two hours of pain-free sleep could be procured. He wrote original jokes which he would read aloud to himself then laugh like crazy. He noticed that every time he laughed, his pain was eased.
Norman Cousins was given a few months to live in 1964. With his rare disease of the connective tissues, he was told by doctors that he had a 1 in 500 chance of survival and to ‘get his affairs in order’. But Cousins would have none of it. A journalist, he was used to research and set himself to find a solution. He read and discovered that both his disease and the medicines were depleting his body of vitamin ‘C’, among other things. He did three things that would be usual today and were unheard of then.
1. He fired his doctor and left the hospital to check into a hotel. He ascertained that the cultural of defeatism, and controversy over medication, in the hospital was not going to be good for his health. He found a doctor who would work with him as a team member as opposed to insisting on being in charge.
2. He began to get injections of massive doses of vitamin ‘C’.
3. He obtained a movie projector, no small feat in those days, and a pile of funny movies including the Marx Brothers and ‘Candid Camera’ shows. He spent a great deal of time watching these films and laughing. And he didn’t just laugh. In spite of being in a lot of constant pain, he made a point of laughing until his very stomach hurt from it.
After Norman Cousins went into remission, he returned to the hospital for a checkup. To the surprise of the medical staff who examined him, they found no trace of the dreaded disease. He was completely cured! They asked Cousins what medicines he took that cured him. They would not believe him when he replied he had not taken any medicine, since he had been told his ailment was incurable. They said, “You must have done something you never did before.” He finally replied, “All I did was to laugh myself to health.” He became known as the man who cured himself through laughter, and was even appointed a faculty member of the University of California Los Angeles School of Medicine, although he was not a doctor.
Later he told his incredible story in a book, “Anatomy of an Illness,” which was made into a movie. At that time, medical science did not believe there was any connection between the mind, the emotions and the immune system. The immune system was thought to be independent of and not subject to the directions of the mind or the vagaries of human emotions. Since then, numerous studies have found that laughter is definitely tied to the healing process. For example, a study conducted at UCLA found that watching funny shows increased children’s tolerance for pain, which could be helpful when tiny patients have to undergo big procedures. At the University of Maryland, researchers found that groups that watched humorous films experienced an increase in blood flow compared to groups that watched downers. That could be because laughter has been called internal jogging, and it may confer all the psychological benefits of a good workout. The act of laughing stimulates hormones called catecholamines, which in turn release endorphins. With endorphins surging through our bloodstream, we’re more apt to feel happy and relaxed. With each laugh, therefore, we’re relieving stress, reducing anxiety and increasing our stores of personal energy. All of these psychological and physiological results are wonderful tools in coping with illness, a hospital stay or even just a cranky coworker.
Researchers at Texas A&M University found that humor leads to increased hopefulness. The researchers believe that laughter can help fight negative thoughts in the brain, and with an increase of positive emotions, people begin to see a way out of their misery. Free from the shackles of negativity, people begin to see how to form a plan of attack to deal with the given situation. Technically speaking laughter is a release of tension, much like sneezing or orgasm. Comics know this well. Watch a good one, no matter what the style you will see that he or she will build up tension and then give some form of punchline to release that tension.
Dr. Lee S. Berk, a preventive care specialist and psychoneuroimmunology researcher at Loma Linda University’s Schools of Allied Health (SAHP) and Medicine, and director of the molecular research lab at SAHP, Loma Linda, CA, has shown in studies that the physiological response produced by belly laughter is opposite of what is seen in classical stress, supporting the conclusion that mirthful laughter is a eustress state — a state that produces healthy or positive emotions. His research results indicate that, after exposure to humor, there is a general increase in activity within the immune system, including the following:
1. An increase in the number and activity level of natural killer cells that attack viral infected cells and some types of cancer and tumor cells.
2. An increase in activated T cells (T lymphocytes). There are many T cells that await activation. Laughter appears to tell the immune system to “turn it up a notch.”
3. An increase in the antibody IgA (immunoglobulin A), which fights upper respiratory tract insults and infections.
4. An increase in gamma interferon, which tells various components of the immune system to “turn on.”
5. An increase in IgB, the immunoglobulin produced in the greatest quantity in body, as well as an increase in Complement 3, which helps antibodies to pierce dysfunctional or infected cells. The increase in both substances was not only present while subjects watched a humor video; there also was a lingering effect that continued to show increased levels the next day
The results of Berk’s study also supported research indicating a general decrease in stress hormones that constrict blood vessels and suppress immune activity. These were shown to decrease in the study group exposed to humor. For example, levels of epinephrine were lower in the group both in anticipation of humor and after exposure to humor. Epinephrine levels remained down throughout the experiment. In addition, dopamine levels (as measured by dopac) were also decreased. Dopamine is involved in the “fight or flight response” and is associated with elevated blood pressure.
Laughing is aerobic, providing a workout for the diaphragm and increasing the body’s ability to use oxygen. Laughter brings in positive emotions that can enhance – not replace — conventional treatments. Hence it is another tool available to help fight the disease.
Experts believe that, when used as an adjunct to conventional care, laughter can reduce pain and aid the healing process. For one thing, laughter offers a powerful distraction from pain. In a study published in the Journal of Holistic Nursing, patients were told one-liners after surgery and before painful medication was administered. Those exposed to humor perceived less pain when compared to patients who didn’t get a dose of humor as part of their therapy. At Swedish Covenant Hospital in Chicago, patients are literally forcing themselves to laugh. The theory is laughter, even if forced, enhances overall well-being and aids in the healing process, using it as a therapeutic tool and not just an emotion. Along with traditional therapies, this is offered as part of their treatment.
Researchers are gathering evidence that laughter can directly affect chemicals in our bodies that influence everything from our brain to our heart. Laughter is thought to decrease stress hormones and lower blood pressure. It may also increase blood flow, even act as a natural pain killer. “For people undergoing chemo, it helps them take the stress and scariness out of it, opens blood flow, and oxygenates the blood so the treatment is flowing a little better throughout their veins,” said Tim Nelson, laughter yoga leader.
At the Chicago Institute of Neurosurgery and Neuroresearch, there is more laughter. Certified laughter therapist Colleen Caron is working with a mix of back patients and health care professionals. “The theory is 10 minutes of laughing can give you up to two hours of pain free,” said Caron. “It’s energizing. It releases the neurotransmitters in the brain, it exercises the same muscles and organs we use for breathing, it stimulates the immune system.”
Even some doctors who deal with high-tech medicine are making room for this low-tech treatment. Dr. Dan Hurley believes in the power of mind and body. He says, in the right situations, a little well placed humor can impact a patient’s outcome. “I think laughter is one of the more magic things we as humans can do innately. It also happens to be therapeutic,” said Dan Hurley, M.D., physiatrist, CINN.
Swedish Covenant says the laughter therapy has been so successful among cancer patients it is now offering the classes to those going through cardiac rehabilitation. This type of therapy is not just reserved for those fighting disease. Therapists such as Colleen Caron also bring their seminars to the work setting as an easy way to help employees relieve stress. The elation you feel when you laugh is a great way of combating the physical effects of stress. When we laugh, our body relaxes and endorphins (natural painkillers) are released into the blood stream. Researchers at the University of Michigan have also calculated that just 20 seconds of laughter could be as good for the lungs as three minutes spent on a rowing machine. Perhaps, the biggest benefit of laughter is that it is free and has no known negative side effects.
Norman Cousins, the pioneer of this form of personalized medical treatment, received the Albert Schweitzer Prize in 1990. He died of heart failure on November 30, 1990, in Los Angeles, California, having survived years longer than his doctors predicted: 10 years after his first heart attack, 26 years after his collagen illness, and 36 years after his doctors first diagnosed his heart disease. He was a courageous medical hero.
The Open Mind: Norman Cousins
Look at this video and don’t laugh
Study Suggests That Moving More May Lower Stroke Risk
A stroke can occur when a blood vessel in the brain gets blocked. As a result, nearby brain cells will die after not getting enough oxygen and other nutrients. A number of risk factors for stroke have been identified, including smoking, high blood pressure, diabetes and being inactive.
According to the NIH, “Here’s yet another reason to get off the couch: new research findings suggest that regularly breaking a sweat may lower the risk of having a stroke.”
For this study, published in the journal Stroke (July 18, 2013), data were obtained from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study. REGARDS is a large, long-term study funded by the NIH National Institute of Neurological Disorders and Stroke (NINDS) to look at the reasons behind the higher rates of stroke mortality among African-Americans and other residents living in the Southeastern United States.
Over 30,000 participants supplied their medical history over the phone. The authors also visited study participants to obtain health measures such as body mass index and blood pressure. At the beginning of the study, the authors asked participants how many times per week they exercised vigorously enough to work up a sweat. The authors contacted participants every six months to see if they had experienced a stroke or a mini-stroke known as a transient ischemic attack (TIA). To confirm their responses, the authors reviewed participants’ medical records.
The authors reported data for over 27,000 participants who were stroke-free at the start of the study and followed for an average of 5.7 years. One-third of participants reported exercising less than once a week. Study subjects who were inactive were 20% more likely to experience a stroke or TIA than participants who exercised four or more times a week. The findings revealed that regular, moderately vigorous exercise, enough to break a sweat, was linked to reduced risk of stroke. Part of the protective effect was due to lower rates of known stroke risk factors such as hypertension, diabetes, obesity and smoking.
The authors also looked at the data according to gender. After the authors accounted for age, race, socioeconomic factors (education and income) and stroke risk factors, the results revealed that men who exercised at least four times a week still had a lower risk of stroke than men who exercised one to three times per week. In contrast, there was no association between frequency of exercise and stroke risk among women in the study. However, there was a trend towards a similar reduction in stroke risk for those who exercised one to three times a week and four or more times a week compared to those who were inactive.
REGARDS will continue to assess stroke risk factors to look for long-term patterns in the study population. According to the authors, findings from this study, including the current physical activity results, will ultimately help to identify potential targets for immediate intervention as well as for future clinical trials aimed at preventing stroke and its consequences.
Laughter is the Best Medicine
According to a study published online in the Proceedings of the Royal Society B (September 2011), having a good laugh with friends really does help deal with pain. Results showed that when we laugh properly, as opposed to producing a polite titter, the physical exertion leaves us exhausted and thereby triggers the release of protective endorphins. These endorphins, one of the complex neuropeptide chemicals produced in the brain, manage pain and promote feelings of well-being. According to the study, watching just 15 minutes of comedy with others increased the pain threshold by an average of about 10%.
According to the authors, releasing endorphins has probably evolved as a way of promoting socializing amongst humans and that many studies have already shown that laughter is 30 times more likely to occur if you are with others than when alone. The endorphin rush appears to be limited to a good belly laugh, shared with others. The study makes an important distinction between relaxed, unforced laughter that creases the eyes, and polite laughter which does not reach the eyes. It concludes that when we laugh properly we produce a series of exhalations without drawing breath, an involuntary physical mechanism that is limited to humans and appears to trigger the release of endorphins. Laughter is important to other great apes too but they breathe in as well as out when they laugh, unlike humans.
The paper is based on more than ten years of research in which different experiments were staged to discover what determined our level of pain tolerance. Subjects were asked to watch TV clips or live staged shows, and their pain thresholds were measured before and after doing this using a number of different pain manipulations (ice-cold sleeves, pressure from a blood pressure cuff, and a painful, strenuous quad work-out). The participants watched 15 minute clips from comedies like Mr. Bean and Friends, and these were contrasted with clips on how to play golf or factual programs, both designed to elicit a neutral response. In other experiments, they watched nature programs designed to produce a positive, ‘feel-good’ quality. However, like the golf instruction clips, these did nothing to increase the pain threshold, suggesting that it is the endorphin-activating effects of laughter itself that is important, not just the feel-good factor.
Another experiment compared the pain thresholds of participants who had watched stand-up comedy at the Edinburgh Fringe Festival with those who sat through staged dramas. This experiment confirmed that the pain tolerance effect of shared laughter is not just something confined to the laboratory, but occurs in real life too.
In both primates and humans, laughter has been found to play an important role, yet has received very little attention in academic literature. This latest paper supports other work that suggests the importance of group activity in producing endorphins. A previous study found that members of a rowing team increased their pain tolerance by training as a group rather than as individuals. Other communal activities like music making, dancing and religious rituals have also been shown to create euphoric states which, according to some studies, can also be associated with the release of endorphins.
TARGET HEALTH excels in Regulatory Affairs. Each week we highlight new information in this challenging area
First Brain Wave Test Cleared to Help Assess Children and Teens For ADHD
ADHD is one of the most common neurobehavioral disorders in childhood. According to the American Psychiatric Association, 9% of U.S. adolescents have ADHD and the average age of diagnosis is 7 years old. Children with ADHD have difficulty with attention, hyperactivity, impulsivity and behavioral problems.
The FDA allowed marketing of the first medical device based on brain function to help assess attention-deficit/hyperactivity disorder (ADHD) in children and adolescents 6 to 17 years old. When used as part of a complete medical and psychological examination, the device can help confirm an ADHD diagnosis or a clinician’s decision that further diagnostic testing should focus on ADHD or other medical or behavioral conditions that produce symptoms similar to ADHD.
The device, the Neuropsychiatric EEG-Based Assessment Aid (NEBA) System, is based on electroencephalogram (EEG) technology, which records different kinds of electrical impulses (waves) given off by neurons (nerve cells) in the brain and the number of times (frequency) the impulses are given off each second. The NEBA System is a 15- to 20-minute non-invasive test that calculates the ratio of two standard brain wave frequencies, known as theta and beta waves. The theta/beta ratio has been shown to be higher in children and adolescents with ADHD than in children without it.
The FDA reviewed the NEBA System through the de novo classification process, a regulatory pathway for some low- to moderate-risk medical devices that are not substantially equivalent to an already legally marketed device.
In support of the de novo petition, the manufacturer submitted data including a clinical study that evaluated 275 children and adolescents ranging from 6 to 17 years old with attention or behavioral concerns. Clinicians evaluated all 275 patients using the NEBA System and using standard diagnostic protocols, including the Diagnostic and Statistical Manual of Mental Disorders IV Text Revision (DSM-IV-TR) criteria, behavioral questionnaires, behavioral and IQ testing, and physical exams to determine if the patient had ADHD. An independent group of ADHD experts reviewed these data and arrived at a consensus diagnosis regarding whether the research subject met clinical criteria for ADHD or another condition. The study results showed that the use of the NEBA System aided clinicians in making a more accurate diagnosis of ADHD when used in conjunction with a clinical assessment for ADHD, compared with doing the clinical assessment alone.
NEBA Health of Augusta, Ga., manufactures the NEBA System.
Kale/Quinoa Fritters with Avocado & Cilantro Topping
1 cup quinoa
2 cups chicken stock or broth
4 eggs, whisked
1/2 cup Parmesan cheese
1 bunch scallions (5 stalks, throw top half away), chopped
3 cloves garlic, (mince 2 cloves, juice of 1 clove)
Pinch Kosher or sea salt
1 cup steamed kale, chopped
1 cup Panko crumbs
1 teaspoon olive oil
Topping: 1 avocado, 3 teaspoons chopped fresh cilantro, juice from ½ lemon, 2 teaspoons extra virgin olive oil, juice of 1 garlic clove
1. Rinse 1 cup of quinoa thoroughly and place the grains in a medium sauce pan with 2 cups of chicken stock or broth. Allow quinoa to soak for 15 minutes. Then, with the lid on the pan, bring the chicken stock to a boil and reduce to a simmer. Cook until quinoa is tender and has absorbed the liquid – about 20 minutes. Let cool to room temp.
2. While the quinoa is cooking, make the topping: Into a small bowl, cut the ripe avocado into pieces or cubes, add 2 teaspoons of your best extra virgin olive oil, add all the juice of ½ a fresh lemon, add the juice of one garlic clove, add 3 teaspoons fresh chopped cilantro and stir all ingredients together. Set aside.
3. In a large bowl, mix together cooked quinoa, eggs, Parm, scallions, minced garlic, salt, steamed kale, and Panko crumbs. Let everything sit for a few minutes to absorb the liquid. You want the batter to be moist, but not runny. Form patties and get your pan ready for cooking.
4. Heat 1 teaspoon olive oil in a large skillet over medium-low heat. Cook up to 6 patties at a time (don’t overcrowd the pan). Cover the pan and let the fritters cook for 7-10 minutes until the under-sides are a deep rich brown. Flip and cook the other side for another 7-10 minutes until both sides are nice and brown. Let patties rest on a cooling rack while you finish the next batch. Serve nice and warm and simply spoon the topping over the fritters. These fritters would go well with a shrimp or sea (or bay) scallop dish, or any favorite fish recipe.
This dish is unbelievably good! Again, my loyal critic said “this is your best!” The fritters are delicious by themselves and double-delish with the avocado topping. I experimented several times, before I got all of the ingredients right and this is the final version. Nice, that they’re so healthy. Nothing is left-over, because my husband eats them out of the fridge, as a yummy snack. They’re gone in 2 days. We had them last night, with the spinach/strawberry/feta/walnut salad (we love it) from last week’s ON TARGET newsletter, and some cut up fresh juicy peaches. In this hot weather, icy Orvieto is our favorite. Stay cool everyone!