eSource Meeting in Philadelphia

 

CBI is running its 3rd meeting addressing eSource Data in Clinical Investigations. Industry leaders will be there and it should be a highly productive experience for all. Dr. Mitchel will be presenting Target Health’s experience of the first FDA product approval where direct data entry occurred at the time of the clinic visit. Using results and experiences during the clinical development of an FDA-cleared de novo 510(k) device, as well as an NDA currently under FDA review, the presentation will take a deep-dive into the processes that were used, including how to:

1. Involve regulators as partners

2. Educate and train the clinical research sites

3. Integrate eSource processes with risk-based monitoring

4. Evaluate the impact on the clinical research enterprise

 

Spring Time in NY

 

Yes, nature is alive in the Big Apple.

 

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On the way to the theatre down Park Avenue on a lovely Spring day. ©Target Health 2016

 

ON TARGET is the newsletter of Target Health Inc., a NYC – based, full – service, contract research organization (eCRO), providing strategic planning, regulatory affairs, clinical research, data management, biostatistics, medical writing and software services to the pharmaceutical and device industries, including the paperless clinical trial.

 

For more information about Target Health contact Warren Pearlson (212-681-2100 ext. 165). 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.

 

Joyce Hays, Founder and Editor in Chief of On Target

Jules Mitchel, Editor

 

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Autism Spectrum Disorder (ASD)

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The puzzle ribbon is an often used symbol for the autism spectrum, as it represents the diversity of conditions and people within it. Source Wikipedia Commons

 

Autism spectrum or autistic spectrum describes a range of conditions classified as neurodevelopmental disorders in the fifth revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5). The DSM-5, published in 2013, redefined the autism spectrum to encompass the previous (DSM-IV-TR) diagnoses of autism, Asperger syndrome, pervasive developmental disorder not otherwise specified (PDD-NOS), and childhood disintegrative disorder. Features of these disorders include social deficits and communication difficulties, stereotyped or repetitive behaviors and interests, sensory issues, and in some cases, cognitive delays. Compared with the DSM-4 diagnosis of autistic disorder, the DSM-5 diagnosis of ASD no longer includes communication as a separate criterion, and has merged social interaction and communication into one category. Rather than categorizing these diagnoses, the DSM-5 has adopted a dimensional approach to diagnosing disorders that fall underneath the autism 1) ___ umbrella. Some have proposed that individuals on the autism spectrum may be better represented as a single diagnostic category. Within this category, the DSM-5 has proposed a framework of differentiating each individual by dimensions of severity, as well as associated features (i.e., known genetic disorders, and intellectual disability).

 

Autism forms the core of the autism spectrum disorders. Asperger syndrome is closest to autism in signs and likely causes; unlike autism, people with Asperger syndrome have no significant delay in language development, according to the older DSM-4 criteria. PDD-NOS is diagnosed when the criteria are not met for a more specific disorder. Some sources also include Rett syndrome and childhood disintegrative disorder, which share several signs with autism but may have unrelated causes; other sources differentiate them from ASD, but group all of the above conditions into the pervasive developmental disorders. Under the DSM-5, autism is characterized by persistent deficits in social communication and interaction across multiple contexts, as well as restricted, repetitive patterns of behavior, interests, or activities. These deficits are present in early childhood, and lead to clinically significant functional impairment. There is also a unique form of 2) ___ called autistic savantism, where a child can display outstanding skills in music, art, and numbers with no practice.

 

Asperger syndrome was distinguished from autism in the DSM-4 by the lack of delay or deviance in early language development. Additionally, individuals diagnosed with Asperger syndrome did not have significant cognitive delays. PDD-NOS was considered “subthreshold autism“ and “atypical autism“ because it was often characterized by milder symptoms of autism or symptoms in only one domain (such as social difficulties). In the DSM-5, both Asperger syndrome and PDD-NOS have been incorporated into autism spectrum 3) ___. CDC’s most recent estimate is that 1 out of every 68 children, or 14.7 per 1,000, have some form of ASD as of 2010. Reviews tend to estimate a prevalence of 6 per 1,000 for autism spectrum disorders as a whole, although prevalence rates vary for each of the developmental disorders in the spectrum. Autism prevalence has been estimated at 1-2 per 1,000, Asperger syndrome at roughly 6 per 1,000, childhood disintegrative disorder at 0.02 per 1,000, and PDD-NOS at 3.7 per 1,000. These rates are consistent across cultures and ethnic groups, as autism is considered a 4) ___ disorder. While rates of autism spectrum disorders are consistent across cultures, they vary greatly by gender, with boys affected far more frequently than girls. The average male-to-female ratio for ASDs is 4.2:1, affecting 1 in 70 males, but only 1 in 315 females. Females, however, are more likely to have associated cognitive impairment. Among those with an ASD and intellectual disability, the gender ratio may be closer to 2:1. Prevalence differences may be a result of gender differences in expression of clinical symptoms, with autistic females showing less atypical behaviors and, therefore, less likely to receive an ASD diagnosis.

 

Autism spectrum disorders are thought to follow two possible developmental courses, although most parents report that symptom onset occurred within the first 5) ___ of life. One course of development is more gradual in nature, in which parents report concerns in development over the first two years of life and diagnosis is made around 3-4 years of age. Some of the early signs of ASDs in this course include decreased looking at faces, failure to turn when name is called, failure to show interests by showing or pointing, and delayed pretend play. A second course of development is characterized by normal or near-normal development followed by loss of skills or regression in the first 2-3 years. Regression may occur in a variety of domains, including communication, social, cognitive, and self-help skills; however, the most common regression is loss of 6) ___. There continues to be a debate over the differential outcomes based on these two developmental courses. Some studies suggest that regression is associated with poorer outcomes and others report no differences between those with early gradual onset and those who experience a regression period. While there is conflicting evidence surrounding language outcomes in ASD, some studies have shown that cognitive and language abilities at age 2 1/2 may help predict language proficiency and production after age 5. Overall, the literature stresses the importance of early intervention in achieving positive longitudinal outcomes.

 

While specific causes of autism spectrum disorders have yet to be found, many risk factors have been identified in the research literature that may contribute to their development. These 7) ___ factors include genetics, prenatal and perinatal factors, neuroanatomical abnormalities, and environmental factors. It is possible to identify general risk factors, but much more difficult to pinpoint specific factors. In the current state of knowledge, prediction can only be of a global nature and therefore requires the use of general markers. Transcranial magnetic stimulation (TMS) has become increasingly popular as a treatment for autism in children, but it’s unclear how effective it is or how long the treatment might last. The basic premise is this: When a powerful magnet generates a magnetic field near the head, the field travels a few centimeters through the scalp and skull, changing the electrical activity of neurons in those locations. The result is a temporary reorganization in the way brain cells communicate with one another. Unlike electroconvulsive therapy, in which electrodes are placed directly on the scalp in order to trigger a seizure, TMS can be targeted to one brain region, and allows for more precise alterations of brain function. It also seems to be gentler than the brutal images associated with the early years of electroconvulsive therapy: TMS is not painful and doesn’t seem to cause amnesia or cognitive problems. The side effects seem limited to headaches and some muscular discomfort, though a few people have had seizures during therapy. TMS can stimulate neurons’ activity or change the signaling patterns of cells that are already active. Given its capacity to do both noninvasively, from the start it offered the promise of a powerful treatment for a range of neuropsychiatric disorders that seem to involve dysfunctions in brain circuits, such as depression, schizophrenia, epilepsy and obsessive-compulsive disorder.

 

In the mid-1990s, researchers began treating depression with repetitive TMS, administering treatment in regular sessions over weeks or months. Initial trials suggested the technique was effective at least some of the time, and in 2007 the U.S. 8) ___ and ___ ___,(FDA) approved it to treat depression in people who don’t respond to medication and talk therapy. It has since also been used to treat chronic pain and to aid recovery from stroke. The University of Louisville has been at the forefront of some of the research on TMS. In typical brains, neurons engage in a perpetual balancing act between excitation and inhibition in response to the endless flow of stimulation that comes their way. Too much inhibition can lead to depression, and too much excitation to both autism and epilepsy. (The latter may explain why many people with autism have seizures and show extreme sensitivity to touch and sound.)

 

Different cells specialize in one activity or the other – stirring up networks or calming things down – and work together to maintain the balance. Research suggests that some of the abnormality in autism brains occurs in mini-columns, vertical networks of cells that work together to process information. Pyramidal cells at the center of these columns are excitatory. Clustered around them, other types of cells, particularly double bouquet cells, turn down the signals so that only the most important information gets through. When this “shower curtain of inhibition“ – a phrase coined by Hungarian scientist Janos Szentagothai – doesn’t work as it should, the signals spill out, drenching the nearby networks in stimulation. In autism, the thinking is that TMS could correct the imbalance between 9) ___ and inhibition. The small currents created by TMS change neurons’ electrical charge and cause them to release chemical messengers, sending a ripple of activity to distant areas of the brain. High-frequency stimulation is thought to increase excitatory activity and a low frequency to increase inhibition. Preliminary results from research with monkeys suggest that people with autism may benefit, for example, from applying TMS to increase excitation in an area of the brain associated with sociability. Because the region is close to the brain’s surface, it is easily accessible to TMS, but is also well connected to the rest of the brain: As a result, any changes there, may have beneficial effects in many other areas. Several of the studies required the participants to perform a visual illusion task designed to trigger a high-frequency brain wave called gamma. Gamma waves are involved in high-level attention processing and have been found to be abnormal in the 10) ___ of people with autism, often responding too strongly to distractions. Studies have found that after repeated bouts of TMS, people with autism process visual information more efficiently, making fewer errors in the illusion task. They are also less irritable and hyperactive and show fewer repetitive behaviors, at least for a while, than before the treatment. The effect is akin to rebooting a computer – something you eventually have to repeat. At its best, TMS can produce dramatic changes.

 

ANSWERS: 1) spectrum; 2) autism; 3) disorder; 4) universal; 5) year; 6) language; 7) risk; 8) Food and Drug Administration; 9) excitation; 10) brains

 

Autism

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The rainbow-colored infinity is often used as a symbol for the diversity of the autism spectrum as well as neurodiversity in general.Source: Eric, Public Domain, Wikipedia Commons

 

The word “autism,“ comes from the Greek word “autos,“ meaning “self.“ The term describes conditions in which a person is removed from social interaction — hence, an isolated self. A few examples of autistic symptoms and treatments were described long before autism was named. The Table Talk of Martin Luther**, compiled by his note taker, Mathesius, contains the story of a 12-year-old boy who may have been severely autistic. Luther reportedly thought the boy was a soulless mass of flesh possessed by the devil, and suggested that he be suffocated, although a later critic has cast doubt on the veracity of this report. The earliest well-documented case of autism is that of Hugh Blair of Borgue, as detailed in a 1747 court case in which his brother successfully petitioned to annul Blair’s marriage to gain Blair’s inheritance. The Wild Boy of Aveyron, a feral child caught in 1798, showed several signs of autism; the medical student Jean Itard treated him with a behavioral program designed to help him form social attachments and to induce speech via imitation.

 

The New Latin word autismus (English translation autism) was coined by the Swiss psychiatrist Eugen Bleuler in 1910 as he was defining symptoms of schizophrenia. He derived it from the Greek word autos (meaning “self“), and used it to mean morbid self-admiration, referring to “autistic withdrawal of the patient to his fantasies, against which any influence from outside becomes an intolerable disturbance“. The word autism first took its modern sense in 1938 when Hans Asperger of the Vienna University Hospital adopted Bleuler’s terminology autistic psychopaths in a lecture in German about child psychology. Asperger was investigating an ASD now known as Asperger syndrome, though for various reasons it was not widely recognized as a separate diagnosis until 1981. Leo Kanner, an American physician, at the Johns Hopkins Hospital first used autism in its modern sense in English when he introduced the label early infantile autism in a 1943 report of 11 children with striking behavioral similarities. Almost all the characteristics described in Kanner’s first paper on the subject, notably “autistic aloneness“ and “insistence on sameness“, are still regarded as typical of the autistic spectrum of disorders. It is not known whether Kanner derived the term independently of Asperger.

 

Kanner’s reuse of autism led to decades of confused terminology like infantile schizophrenia, and child psychiatry’s focus on maternal deprivation led to misconceptions of autism as an infant’s response to “refrigerator mothers“. Starting in the late 1960s autism was established as a separate syndrome by demonstrating that it is lifelong, distinguishing it from intellectual disability and schizophrenia and from other developmental disorders, and demonstrating the benefits of involving parents in active programs of therapy. As late as the mid-1970s there was little evidence of a genetic role in autism; now it is thought to be one of the most heritable of all psychiatric conditions. Although the rise of parent organizations and the destigmatization of childhood ASD have deeply affected how we view ASD, parents continue to feel social stigma in situations where their child’s autistic behavior is perceived negatively by others, and many primary care physicians and medical specialists still express some beliefs consistent with outdated autism research.

 

The Internet has helped autistic individuals bypass nonverbal cues and emotional sharing that they find so hard to deal with, and has given them a way to form online communities and work remotely. Sociological and cultural aspects of autism have developed: some in the community seek a cure, while others believe that autism is simply another way of being. The emergence of the autism rights movement has served as an attempt to encourage people to be more tolerant of those with autism. Through this movement, people hope to cause others to think of autism as a difference instead of a disease. Proponents of this movement wish to seek “acceptance, not cures.“ There have also been many worldwide events promoting autism awareness such as World Autism Awareness Day, Light It Up Blue, Autism Sunday, Autistic Pride Day, Autreat, and others. There have also been many organizations dedicated to increasing the awareness of autism and the effects that autism has on someone’s life. These organizations include Autism Speaks, Autism National Committee, Autism Society of America, and many others. Social-science scholars have had an increased focused on studying those with autism in hopes to learn more about “autism as a culture, transcultural comparisons and research on social movements.“ Media has had an influence on how the public perceives those with autism. Rain Man, a film that won 4 Oscars, depicts a character with autism who has incredible talents and abilities. While many autistics don’t have these special abilities, there are some autistic individuals who have been successful in their fields.

 

**Martin Luther’s Table Talk (German: Tischreden) is a collection of his sayings around the dinner table at the Black Cloister, Luther’s home, but also at other times and locations, such as walks in the garden or notes taken while on journeys. It is based on notes taken by various students of Luther between 1531 and 1544. It was compiled by Johannes Mathesius, J. Aurifaber, V. Dietrich, Ernst Kroker, and several others, and published at Eisleben in 1566. Mathesius spoke enthusiastically of the privilege of eating with Luther and hearing him converse. Earlier note takers had written down only the serious remarks of Luther, but Mathesius also wrote down the facetious or even damaging remarks, a sign of the increasing reverence in which Luther was held.

 

Patients with Rosacea Have Increased Risk of Dementia

 

Rosacea is a common chronic inflammatory skin disorder where upregulation of matrix metalloproteinases (MMPs) and antimicrobial peptides (AMPs) is observed. Notably, inflammation, MMPs, and AMPs are also involved in the etiopathogenesis of neurodegenerative disorders including certain forms of dementia such as Alzheimer disease (AD). As a result, a study published in the Annals of Neurology (28 April 2016), was performed to investigate the association between rosacea and dementia, including AD in Danish registers.

 

For the study, all Danish citizens aged >18 years between January 1, 1997 and December 31, 2012 were linked at the individual level through administrative registers. When this was done, the study was able to identify a total of 5,591,718 individuals, including 82,439 patients with rosacea. Of these individuals, a total of 99,040 developed dementia (any form) during the study period, and 29,193 were diagnosed with AD. The adjusted hazards ratios HRs) of dementia and AD were 1.07 and 1.25, respectively, in patients with rosacea. Stratified by gender, the HRs of AD were 1.28 and 1.16 in women and men, respectively. When results were stratified by age at study entry, the risk of AD was only significantly increased in individuals >60 years old (adjusted HR = 1.20). When analyses were limited to patients with a hospital dermatologist diagnosis of rosacea only, the adjusted HRs of dementia and AD were 1.42 and 1.92, respectively.

 

According to the authors, rosacea is significantly associated with dementia, particularly AD, and that increased focus on symptoms of cognitive dysfunction in older patients with rosacea may be relevant.

 

Trigeminal Nerve Stimulation (TNS) For Treating Major Depression

 

The trigeminal nerve (the fifth cranial nerve, or simply CN V) is a nerve responsible for sensation in the face and motor functions such as biting and chewing. The largest of the cranial nerves, its name (“trigeminal“ = tri-, or three and -geminus, or twin; thrice-twinned) derives from the fact that each trigeminal nerve (one on each side of the pons) has three major branches: the ophthalmic nerve (V1), the maxillary nerve (V2), and the mandibular nerve (V3). The ophthalmic and maxillary nerves are purely sensory, and the mandibular nerve has sensory (or “cutaneous“) and motor functions.

Major depressive disorder (MDD), often simply called depression, is a mental disorder characterized by a pervasive and persistent low mood that is accompanied by low self-esteem and by a loss of interest or pleasure in normally enjoyable activities. MDD is a disabling condition that adversely affects a person’s family, work or school life, sleeping and eating habits, and general health. In the United States, around 3.4% of people with major depression die by suicide, and up to 60% of people who die by suicide had depression or another mood disorder.

According to an article published online in Epilepsy and Behavior (23 August 2014), an open-label proof-of-concept trial using Trigeminal Nerve Stimulation (TNS) for MDD was performed that according to the authors was the first study that evaluated a TNS interventional protocol for the treatment of MDD. For the study, a total of 11 patients (10F; 1M) were studied, with a mean age of 50.36 years (range of 30 to 60). Results showed that there was a reduction of depressive symptoms with a mean score of 5.72 (p<0.001) on the original 17-item Hamilton Depression Rating Scale (HDRS-17). All patients presented clinical response defined as a reduction of scores of at least 50%. Only one patient did not reach a remission score (defined as an HDRS score lower than 8).

The authors concluded that the data analysis provided significant support to use TNS in ameliorating depressive symptoms of patients with moderate or severe depressive episode, but that further controlled studies will contribute to establish the clinical relevance of this new strategy for MDD.

As a followup, a study was presented at the American Society of Clinical Psychopharmacology (ASPC) 2015 Annual Meeting where results were presented that showed, in a sham treatment controlled study that TNS may be a useful adjunctive treatment for patients with MDD that is not adequately controlled by antidepressant medication. The study included 43 adults aged 23 to 65 years with nonpsychotic unipolar MDD who were unresponsive to more than 6 weeks of treatment with at least one antidepressant. Participants were randomly assigned to receive active stimulation or control sham stimulation for 6 weeks. They self-stimulated the trigeminal nerve for 8 hours each night at home using patch electrodes placed on the forehead.

Clinical outcomes were assessed using the Beck Depression Inventory (BDI), the Inventory of Depressive Symptomology (IDS-SR), and the Hamilton Depression Rating Scale (HDRS-17). Results showed that patients receiving active stimulation had significantly greater symptom improvement at week 6 than patients receiving the control condition on the BDI, and they approached significance on the IDS-SR.

Table. Symptom Improvement With TNS vs Sham

Rating TNS Sham P-value
BDI -41.7% -10.9% 0.013
IDS-SR -30.3% -2.5% 0.060
HDRS-17 -36.8% -30.5% n.s.

 

However, symptom severity for all scales improved significantly for patients receiving active stimulation. The mean score on the BDI fell from 24.6 at baseline to 14.2 at week 6 (P <0.00001; the mean score on the IDS-SR fell from 38.3 to 26.1 (P >0.00001), and the HDRS-17 score fell from 19.4 to 12.1 (P < .0001).

 

Drug Approved to Treat Hallucinations/Delusions Associated with Parkinson’s Disease

 

According to the National Institutes of Health, an estimated 50,000 Americans are diagnosed with Parkinson’s disease (PD) each year, and about one million Americans have the condition. The neurological disorder typically occurs in people over age 60, when cells in the brain that produce a chemical called dopamine become impaired or die. Dopamine helps transmit signals between the areas of the brain that produce smooth, purposeful movement — like eating, writing and shaving. Early symptoms of the disease are subtle and occur gradually. In some people PD progresses more quickly than in others. As the disease progresses, the shaking, or tremor, which affects the majority of people with PD, may begin to interfere with daily activities. Other symptoms may include depression and other emotional changes; hallucinations and delusions; difficulty in swallowing, chewing, and speaking; urinary problems or constipation; skin problems; and sleep disruptions.

 

Hallucinations or delusions can occur in as many as 50% of patients with PD at some time during the course of their illness. People who experience them see or hear things that are not there (hallucinations) and/or have false beliefs (delusions). The hallucinations and delusions experienced with PD are serious symptoms, and can lead to thinking and emotions that are so impaired that the people experiencing them may not relate to loved ones well or take appropriate care of themselves.

 

The FDA has approved Nuplazid (pimavanserin) tablets, the first drug approved to treat hallucinations and delusions associated with psychosis experienced by some people with PD. The effectiveness of Nuplazid was shown in a six-week clinical trial of 199 participants. Nuplazid was shown to be superior to placebo in decreasing the frequency and/or severity of hallucinations and delusions without worsening the primary motor symptoms of PD. As with other atypical antipsychotic drugs, Nuplazid has a Boxed Warning alerting health care professionals about an increased risk of death associated with the use of these drugs to treat older people with dementia-related psychosis. No drug in this class is approved to treat patients with dementia-related psychosis. In clinical trials, the most common side effects reported by participants taking Nuplazid were: swelling, usually of the ankles, legs, and feet due to the accumulation of excessive fluid in the tissue (peripheral edema); nausea; and abnormal state of mind (confused state).

 

Nuplazid was granted breakthrough therapy designation for the treatment of hallucinations and delusions associated with PD. Breakthrough therapy designation is a program designed to expedite the development and review of drugs that are intended to treat a serious condition and where preliminary clinical evidence indicates that the drug may demonstrate substantial improvement over available therapy on a clinically significant endpoint. The drug was also granted a priority review. The FDA’spriority review program provides for an expedited review of drugs that offer a significant improvement in the safety or effectiveness for the treatment, prevention, or diagnosis of a serious condition.

 

Nuplazid is marketed by Acadia Pharmaceuticals Inc. of San Diego, California.

 

Awesome Asparagus Appetizer

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So-o delicious, so healthy, so pretty, so easy and still in season. ©Joyce Hays, Target Health Inc.

 

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Only 3 Delicious ingredients. ©Joyce Hays, Target Health Inc.

 

 

Directions

 

1. First, rinse off the asparagus and dry them. Then, snap off the tough ends of the asparagus. They know where to break. Discard the ends.

 

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Just snapped off the tough ends. ©Joyce Hays, Target Health Inc.

 

 

2. You want to use the top part of the asparagus, but only about 2.5 inches, so cut all the asparagus tops to be approximately 2.5 inches long. These ends are still tender and useable, so save them for a salad or soup. I’m experimenting with soup this week with my cut off asparagus ends, and if presentable, will share a soup recipe next week.

 

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Cut 2.5 length spears but save the ends for soup, etc. ©Joyce Hays, Target Health Inc.

 

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Save the ends for soup or salad, etc. ©Joyce Hays, Target Health Inc.

 

 

3. Because asparagus is still in season, hence tender, I probably didn’t need to do this next step, but I did it anyway. I added to a skillet, a few drops of extra virgin olive oil (I only buy this, and use it for everything — it’s gotta say “extra virgin“ on the bottle), and with some paper towel oiled, then wiped it off. When you pick up the asparagus later, you don’t want to feel oil on it.

4. Next, over medium flame, I added a few drops of water to the pan, and then the 2.5 asparagus spears, and covered the pan. You want the spears to steam for 1 minute only, so remove from pan immediately.

 

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Steam the spears for 1 minute only, then remove to a dish. ©Joyce Hays, Target Health Inc.

 

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After steaming for 1 minute only, remove from pan and put in a dish. ©Joyce Hays, Target Health Inc.

 

 

5. Next, take pieces of the salmon and spread them with the Tofutti. The difference between Tofutti and cream cheese is barely discernable, so we have switched forever, from cream cheese to Tofutti, for everything that requires cream cheese. And, btw, this includes weekend brunch: grinding our own coffee beans for nice hot mugs of coffee, and wonderful New York bagels with Tofutti & Nova. Nothing says NY like a bagel! Right? (Ah, yes, life can be so good)

 

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Here, I am spreading Tofutti on slabs of salmon. The pieces, above, are too big to roll around an asparagus spear, so they will be cut down to size, on this cutting board. Buy your salmon from a fish monger and not in a pre-sealed pack. You want to stand there, kibitz about the best salmon (there are many varieties), and tell him or her, to slice it as thin as possible. Buying this velvety fish is an event in itself!   ©Joyce Hays, Target Health Inc.

 

 

6. Take a thin strip of salmon covered with Tofutti, and put one 2.5 asparagus spear at one end of the salmon strip. Now, just roll the asparagus up in the salmon. You don’t need any toothpicks to hold the salmon in place.

 

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Starting to roll up the asparagus spears, in salmon strips. ©Joyce Hays, Target Health Inc.

 

 

7. Finally, put the rolled up awesome asparagus appetizers on a serving plate, arranged to show them off. Serve with a chilled white wine like chardonnay, sauvignon blanc, pinot noir, champagne, Riesling and these days, we’re loving Louis Jadot Pouilly-Fuisse, a white burgundy experience worth having.

 

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Finger food or with utensils, they’re so good, they disappear fast. You won’t have to worry about left-overs. ©Joyce Hays, Target Health Inc.

 

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Two more bites and they’re gone! ©Joyce Hays, Target Health Inc.

 

 

This yummy dish is extremely versatile. As an appetizer before a main course, they’re perfect. On a brunch buffet spread, can’t you see a couple of these, on your plate, next to some moist scrambled, fried or poached eggs? Even when asparagus is not in season, Jules and I would enjoy these on a warm summer evening, as the main meal, with some good French country baguettes, and icy white wine.

 

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Just want to share with you, a white French burgundy wine, gentle yet complex, silken not sweet, that we’re enjoying immensely this week. It went well with the amazing asparagus appetizer and the salmon. Btw, both asparagus and salmon are often difficult to pair wine with. This Pouilly-Fuisse went well with both the veggie and the fish. ©Joyce Hays, Target Health Inc.

 

 

From Our Table to Yours !

 

Bon Appetit!