Blood vessels are susceptible to damage secondary to chronic inflammation. Thus, it’s easy to understand the heart and kidney disease which are prominent in subjects with poor oral hygiene. The report summarized below, from JAMA Oncology, strongly suggests that common pathogens found in patients with periodontal disease are associated with the subsequent development of pancreatic cancer. This report adds to the list of undesirable outcomes that afflict those with bad oral hygiene.

The report is suggestive rather than definitive, but there are already plenty of data to support the salutary effects of maintaining oral health. Brushing, flossing, and regular visits to a dentist are already documented to convey major health benefits that go beyond the oral cavity. The physician who is either a generalist or a specialist treating a condition that is either generated or worsened by periodontal disease should reinforce the essential need to treat the disorder because of its harmful effects on general health.

Oral Bacterial and Fungal Microbiome and Subsequent Risk for Pancreatic Cancer

Key Points

Question  Is the prediagnostic oral bacterial and fungal microbiome associated with the subsequent development of pancreatic cancer?

Findings  In this cohort study including 122 000 individuals, 3 oral bacterial periodontal pathogens, an additional 20 bacteria, and 4 fungi were identified, which together conferred a more than 3-fold increase in the risk for pancreatic cancer.

Meaning  The oral fungal and bacterial microbiotas may serve as readily accessible, noninvasive biomarkers for subsequent pancreatic cancer risk to identify individuals at high risk of pancreatic cancer.

Abstract

Importance  The oral microbiota may be involved in the development of pancreatic cancer, yet current evidence is largely limited to bacterial 16S amplicon sequencing and small retrospective case-control studies.

Objective  To test whether the oral bacterial and fungal microbiome is associated with the subsequent development of pancreatic cancer.

Design, Setting, and Participants  This cohort study used data from 2 epidemiological cohorts: the American Cancer Society Cancer Prevention Study-II Nutrition Cohort and the Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial. Among cohort participants who provided oral samples, those who prospectively developed pancreatic cancer were identified during follow-up. Control participants who remained free of cancer were selected by 1:1 frequency matching on cohort, 5-year age band, sex, race and ethnicity, and time since oral sample collection. Data were collected from August 2023 to September 2024, and data were analyzed from August 2023 to January 2025.

Exposures  The oral bacterial and fungal microbiome were characterized via whole-genome shotgun sequencing and internal transcribed spacer (ITS) sequencing, respectively. The association of periodontal pathogens of the red complex (Treponema denticola, Porphyromonas gingivalis, and Tannerella forsythia) and orange complex (Fusobacterium nucleatum, F periodonticum, Prevotella intermedia, P nigrescens, Parvimonas micra, Eubacterium nodatum, Campylobacter shower, and C gracilis) with pancreatic cancer was tested via logistic regression. The association of the microbiome-wide bacterial and fungal taxa with pancreatic cancer was assessed by Analysis of Compositions of Microbiomes With Bias Correction 2 (ANCOM-BC2). Microbial risk scores (MRS) for pancreatic cancer were calculated from the risk-associated bacterial and fungal species.

Main Outcomes and Measures  Pancreatic cancer incidence.

Results  Of 122 000 cohort participants who provided samples, 445 developed pancreatic cancer over a median (IQR) follow-up of 8.8 (4.9-13.4) years and were matched with 445 controls. Of these 890 participants, 474 (53.3%) were male, and the mean (SD) age was 67.2 (7.5) years. Three oral bacterial periodontal pathogens—P gingivalis, E nodatum, and P micra—were associated with increased risk of pancreatic cancer. A bacteriome-wide scan revealed 8 oral bacteria associated with decreased and 13 oral bacteria associated with increased risk of pancreatic cancer (false discovery rate–adjusted Q statistic less than .05). Of the fungi, genus Candida was associated with increased risk of pancreatic cancer. The MRS, based on 27 oral species, was associated with an increase in pancreatic cancer risk (multivariate odds ratio per 1-SD increase in MRS, 3.44; 95% CI, 2.63-4.51).

Conclusions and Relevance  In this cohort study, oral bacteria and fungi were significant risk factors for pancreatic cancer development. Oral microbiota hold promise as biomarkers to identify individuals at high risk of pancreatic cancer, potentially contributing to personalized prevention.

Franco Zeffirelli’s 1981 production still delivers the ambience that lets Puccini’s remarkable score dazzle even the most jaded opera goer. I’ve been attending La Bohème for 70 years, and it still works. The characters are all ordinary people mispending their youth. They’ll never amount to much, but Puccini’s magic makes us care about them. After their youth is gone, they’ll return home to their native villages and teach school. Rodolfo will mostly forget Mimì and father a brood of children who will waste their young years.

The two most important characters are, of course, Mimì and Rodolfo. They were played and sung with feeling and sensitivity by Juliana Grigoryan and Freddie De Tommaso. Ms Grigoryan is a beautiful woman who looks too healthy for the consumptive seamstress. She’s very young and her characterization will doubtless add depth as she gains more experience – an artist on the ascent.

British tenor De Tomasso has a bright voice that is well suited for Puccini’s starving playwright. The only problem is that he has the tenor’s occupational body habitus – he’s in danger of assuming the shape of a manatee. The rest of the Bohemians were likewise overupholstered. We can knock off 30 pounds per performer as an opera allowance.

The cast was all very good. Particularly fine was Lucas Meachem as Marcello. It’s not a part that usually gets a lot of attention, but he gave the painter a simple gravitas and made a real person out of what can be a stock character.

Maestra Keri-Lynn Wilson led the Met’s orchestra to a fine realization of Puccini’s unique sound. The orchestra could play the score to perfection via Zoom if needed. The chorus and cast of thousands brought off Puccini’s Helzapopin Act 2 with panache.

I don’t need to say much more. La Bohème speaks for itself and defeats elitist critics who find it too easy to assimilate. The opera is a wonder that only a great master could conjure. If you like the opera, and you must be deranged or terminally snobbish not to, catch the replay if you missed today’s live broadcast. You might want to see the replay even if you were at today’s performance. Viva Puccini!

La Bohème
Giacomo Puccini | Luigi Illica/Giuseppe Giacosa

Mimì……….Juliana Grigoryan
Rodolfo……….Freddie De Tommaso
Musetta……….Heidi Stober
Marcello……….Lucas Meachem
Schaunard……….Sean Michael Plumb
Colline……….Jongmin Park
Benoit/Alcindoro……….Donald Maxwell
Parpignol……….Gregory Warren
Sergeant……….Jonathan Scott
Officer……….Ned Hanlon

Conductor……….Keri-Lynn Wilson
Video Director……….Gary Halvorson

The Met’s first problem is poor leadership. General Manager Peter Gelb has one positive accomplishment in nearly two decades on the job – the HD telecasts of live Met productions. Outside of this important achievement, his tenure has been drab. He has needlessly involved the company in international politics, as if opera house politics were not deadly enough.

He has dismissed some of the company’s brightest stars for behavior that the Met has known about for many years. Anna Netrebko was let go for being Russian, only to have Gelb engage a succession of lesser Russian singers. Jame Levine and Placido Domingo were sent packing without a goodbye. Gelb has the loyalty of a clam. Levine and Domingo didn’t even get a gold watch. Then he hires a bunch of Russian singers without making them denounce Vladimir Putin. He also hires his wife to lead the band.

If previous GMs were as sensitive to sexual peccadillos, Caruso would have been fired after the Monkey House incident in Central Park in 1906. Ezio Pinza was said to be a fanny pincher, Beniamino Gigli has several families and scattered bastards around he world. Toscanini slept with most of his leading sopranos. None was disciplined by the Met. So by previous standards, Gelb is at least a prude. But if he were any good at the core of his job this bourgeois failing could be overlooked.

Gelb’s biggest blemish is his financial mismanagement. He repeatedly schedules expensive productions that fail at the box office or require rapid replacement, such as his La Sonnambula debacle. Two productions of this infrequently performed opera in 15 years is a sign that the GM doesn’t know what he’s doing. Tosca and Traviata both had to have premature replacement productions because of inferior new productions that should have lasted for decades. A wonderful Aida was replaced with a piece of treacle. Consider Zefferelli’s Bohème, which is still wowing the audience long after its producer has departed the proscenium.

The company’s endowment is only about $255 million, down about $100 million from the previous year. They had to use the endowment to cover operating expenses which reflects poor fiscal management. The endowment is very small considering the size and importance of the Met in the opera world.

Gelb’s programming continually force-feeds the Met’s audience inferior new works that are enormously expensive to mount and which fail to attract a sufficient audience. The company’s record of success with new productions is virtually nonexistent. Of all their premiere’s only two have been of works that endured, both by Puccini.

Behind the glitter of the Lincoln Center palace lies an infrastructure that’s crumbling (as are the exterior walls of the center’s buildings) due to inadequate care and attention. Not all of the decay is the fault of management. Tastes and skill sets vary with time. Opera, as a popular diversion, has receded into the shadows as movies and their congeners have claimed both creative talent and the public’s attention. It may be that there is no longer room for the art form to thrive, save as a memory.

Verdi is at the core of the operatic repertory, yet the company has no Verdi singers of genius. They can do Puccini, but Verdi is currently a big problem. They’ve tried Germanic singers in key Verdi roles without a felicitous result. It’s not an accident that there’s no Verdi opera on the company’s HD list for this season.

Regardless of externals and immutables, the company could be run with more regard for efficiency and the tastes of its audience. At more than $300 a ticket, said audience is apt to be as scarce as it is gray. Of course, efficiency, the need to fill an auditorium with 4,000 seats, and the presence of no one knows how many unions make for an immovable sludge. The Met’s palace cum theater does the company more harm than good. It would be far better off to present opera using its up-and-coming talent at a smaller venue where it could offer a different bill of fare. But that’s like asking the New York Yankees to play at Marine Park. And the ball club has a much larger and devoted audience.

The Met is a prisoner of its past and present. The former glorious, the latter mired in fly paper. I doubt if the company could be saved even if it were managed by someone who knew what he was doing. Short of Elon Musk coming to the rescue as he did for Twitter, I see nothing but dark days ahead. And Musk has shown no indication that he has any inclination for music, much less the kind that emanates from an opera house.

The Met may endure, but if it does, it will be a sideshow. And as if things weren’t bad enough, it’s in New York.

The duet is found in several places on this site. But I’ve never devoted an entire post to it. Below are 11 interpretations of it sung by noted artists. Most of these selections have not appeared here before. The Italian text with an English translation is at the end of this article.

From a 1943 recording Giacomo Lauri-Volpi is joined by Gino Bechi. The tenor enjoyed a remarkably successful career that spanned 40 years. He appeared to great acclaim at all the world’s great houses. Yet I’ve never cared for his voice. I find it unattractive and somewhat shrill and forced. Given the success and acclaim he enjoyed my opinion must be an outlier. Baritone Gino Bechi had a very successful career based mainly in Italy. He had a big and virile voice which can be heard on numerous recordings.

In 1953, in New Orleans, Mario Del Monaco and Leonard Warren participated in a staged performance of Forza. This excerpt is from that show.

Two duets featuring Giueppe Di Stefano are from 1955 and 1960. The ’55 excerpt is from a La Scala performance. Di Stefano’s partner is Aldo Protti. I’ve recently written about him. Note how good he is in this duet. This period was at the tail end of Di Stefano’s peak. He’s in terrific form. Of course, Alvaro is a role he shouldn’t have sung, but his emotional commitment is so palpable that it’s easy to understand why he and his conductors and directors wanted him to stray from the roles best suited to his beautiful lyric voice. By 1960, he was well on the downward path; yet, in this performance in Vienna, he managed to pull himself together and deliver an outstanding performance. It was perhaps the last time he was at his best. First 1955, then 1960. The baritone in the second clip is Ettore Bastianini.

Net two featuring Luciano Pavarotti. He never sang the complete opera in performance. He felt it was a bad luck opera. Leonard Warren had died in the middle of a performance of it in March 1960. These two excerpts are from recitals. The first is with baritone Piero Cappuccilli. The second is with the very young Dmitri Hvorostovsky. It was made several years before the Russian singer made his first Met appearance.

The next duet is from a Met performance featuring Giuseppe Giacominini and Leo Nucci.

This selection is taken from the complete performance of the opera featuring Jonas Kaufmann and Ludovic Tezier.

Jose Carreras and Piero Cappuccilli recorded the duet in 1981 before Carreras was stricken with leukemia. He recovered and returned to singing, but his voice was never again at the standard it reached before his serious illness.

More recently, tenor Jonathan Tetelman and baritone Adam Unger recorded the duet. It’s with an organ accompaniment which sounds okay. Tetelman recently made his Met debut.

Finally, a recording that’s appeared here before. The now legendary version sung by Richard Tucker and Robert Merrill at the 1972 Gala in honor of Sir Rudolf Bing. It features Merrill’s cosmic finalmente.

Drinking More Than 1 Can of Any Soda Daily Linked to Liver Disease

The following is a quotation from the news report: A study of nearly 124,000 people found that drinking just one daily serving of artificially sweetened drinks increased the risk of a liver disease known as nonalcoholic fatty liver disease or metabolic dysfunction-associated steatotic liver disease (MASLD).

It’s from a British study that has not yet gone through peer review. It’s a self-reported study which always adds uncertainty to the data. It also has many uncontrolled variables, at least according to the press report. First, who gets fatty liver disease? The list below shows the major risk factors for the disorder. Who were the control groups for this study? Were they the same, save for their propensity to drink artificially sweetened drinks? Who drinks these beverages? People who are already at risk for fatty liver disease – ie, the obese.

For this study to have any meaning (I’m faulting the reporter who may not have had the full extent of the study, though, I doubt that’s the whole explanation) it would have controlled for all the other variables that predispose to fatty liver disease except for the consumption of artificially sweetened drinks.

Such a study would be very difficult and certainly could not be done by self reporting. Another conclusion to these data could easily be that people at the highest risk for fatty liver disease drink artificially sweetened drinks. It’s even possible that they may be reducing their risk by keeping their weight down. This is pure conjecture on my part, but it’s a possibility no matter how remote.

It’s hard enough to get decisive medical advice from your general physician who may not be well-trained in clinical investigation, epidemiology, and study design. But you certainly won’t get it from the lay press. Aeger medicīnālis, cave!

Obesity – especially central (abdominal) obesity
Type 2 diabetes mellitus
Insulin resistance or metabolic syndrome
Dyslipidemia – high triglycerides and/or low HDL cholesterol
Hypertension
Sedentary lifestyle and poor diet (high in sugar, refined carbs, and saturated fats)
Genetic predisposition (variants in genes like PNPLA3, TM6SF2, MBOAT7)
Age – risk increases with age
Sleep apnea
Polycystic ovary syndrome
Hypothyroidism and hypopituitarism
Medications – e.g., corticosteroids, tamoxifen, methotrexate, amiodarone

The bass aria ‘O tu Palermo’ is sung by Procida at the beginning of Act 2. He has returned from exile to lead the Sicilians in revolt against their French occupiers. In it he expresses his his joy at returning to his native land and city.

The eight versions below are all sung in Italian. They include the recitative that precedes the aria. It is one of the finest solos for bass written by Verdi.

Ezio Pinza sang 879 performances at the Met between 1926 and 1948. He then went on to become a Broadway star creating the role of Emile de Becque in Rogers and Hammerstein’s South Pacific.

Boris Christoff was the mid 20th century bass whose dramatic impact came closest to Chaliapin’s. In 1950 he was invited to sing at the Metropolitan Opera in New York City but was refused entry into the USA as a result of the McCarran Immigration Act, which banned citizens of Eastern bloc countries from entering the country. This refusal was ordered despite Christoff’s opposition to communism. He refused any further invitations to the Metropolitan and never appeared there. His dark sound was ideal for the most intense parts such as Verdi’s Philip II and Mussorgsky’s Boris Godunov. His recording includes some of the dialogue that follows the aria.

Cesare Siepi took Christoff’s place in Rudolf Bing’s first production at the Met in 1950. He was Philip II in Don Carlo. He takes a very lyrical approach to the Vespri aria. It was this type of singing along with his good looks that made him an ideal Don Giovanni. He was a regular at the Met giving 491 performances between 1950 and 1973. He left the company because of a dispute with management while he was still at the peak of his vocal powers.

Bonaldo Giaiotti was a leading basso cantante of the middle of the last century. He was a regular at most of the world’s leading opera houses. Between 1960 to 1989 he appeared 414 times at the Met.

Giorgio Tozzi (born George John Tozzi in Chicago) sang 528 performances with the Met between 1955 and 1975. He appeared at virtually all of the world’s major opera houses. After dubbing the singing voice for the character of Emile de Becque (portrayed by Rossano Brazzi) in the 1958 film version of South Pacific, he spent many years playing the role of de Becque himself in various revivals and road tours of the show, including one at Lincoln Center in the late 1960s. After his singing career ended he taught at the Juilliard School, Brigham Young University, and Indiana University.

Nicolai Ghiaurov was one of the world’s greatest basses. He was especially known for his Verdi and Mussorgsky roles. Married to soprano Mirella Freni they frequently sang together. In Ghiaurov’s obituary in Opera News, Martin Bernheimer remarked: “He commanded a remarkable vocal instrument, strikingly generous in size, warm in timbre, dark in color. He rolled out the resonant tone at his command with generosity, and with special ease at the burnished top.”

Ferruccio Furlanetto has been one of the most successful basses in recent memory. Though 76 years old, he is still performing. He made his Met debut in 1980. In 1982 he sang the role of Procida with the company. His last appearance at the Met was in 2022. Thus far he has appeared 228 times with the company.

Ildar Abdrazakov is a Russian bass who is in the middle of a very successful career. He has appeared 177 times with the company.

The Sicilian Vespers has only been done 45 times by the Met. Its last appearance at the New York house was in 2004. Given the expensive stuff the Met has been feeding a reluctant audience, the reappearance of a neglected Verdi masterpiece is way overdue.

O patria, o cara patria, alfin ti veggo!
L’esule ti saluta
Dopo sì lunga assenza;
Il tuo fiorente suolo
Bacio, e ripien d’amore
Reco il mio voto a te, col braccio e il core!
O tu, Palermo, terra adorata,
a me sì caro riso d’amor, ah!
Alza la fronte tanto oltraggiata,
il tuo ripiglia primier splendor!
Chiesi aita a straniere nazioni,
ramingai per castella e città;
ma, insensibil al fervido sprone,
dicea ciascun: siciliani, ov’è il prisco valor?
Su, sorgete a vittoria, all’onor!

O fatherland, dear motherland, I see you in the end!
The exile greets you
After such a long absence;
Your flourishing soil
Kiss, and love again
I give my vote to you, with the arm and the core!
O you, Palermo, adored land,
Of my green years – laughter of love,
Raise your forehead so outraged,
Your recovery – premier splendor!
I asked to foreign countries,
I wandered through castles and cities:
But, insensitive to fervid spurs,
Respond with vain pity! –
Sicilians! Where is the ancient valor?
Come on, rise to victory, to honor!

First is the need for a new production of an opera that the company has given only 82 times (counting today’s presentation) since it first appeared in the Met’s inaugural season in 1883. Its last production was in 2009. It was so awful that it lasted for only 15 performances. La Sonnambula persists only if a star soprano wants to do it. Nadine Sierra is such a soprano and obviously wanted to sing the role of Amina. The 2009 production was beyond resucitation and an expensive redo was required. This pattern of bad productions followed by a premature new one happens a lot at the Met and ruptures the company’s budget. Who’s responsible for these messes – Peter Gelb.

The GM opened the telecast with an unnecessary foray into a political topic. Such detours are a regular part of Gelb’s administration. He drove the world’s greatest soprano (Anna Netrebko) away because she was Russian. She’s suing both the Met and Gelb for breach of contract, defamation, and discrimination (national origin and gender). Since he let Netrebko go, he’s cast a carload of Russians, including Alexander Vinogradov who appeared in today’s show as Count Rodolfo.

Enough! How was the performance? Fine if you can get past the silly story which director Rolando Villazón took far too seriously. His Swiss villagers, all clad in black and with a mien to match, looked as if they had been hijacked from Lancaster County. In his intermission interview he found meaning where there was none. He had Amina reject Elvino at the opera’s end and climb a ladder instead of reuniting with him. Still, it was nothing like Mary Zimmerman’s 2009 catastrophe. It won’t need replacement the next time a star soprano feels a yen for La Sonnambula.

Nadine Sierra is now at the peak of her vocal powers. and it’s very high. She’s also as good to look at as she is to hear. Her portrayal of the sleepwalking soprano was as close to perfect as a soprano can be when charged with emitting Bellini’s famously “long, long long” melodies (Verdi’s description). Her acting, not that acting is very important in this opera, gave us a loveable dimwit given to grimaces and other strange faces that Gary Halvorson’s closeups made easily visible to the TV audience. Those in the Met’s auditorium may not have noticed. These quirks didn’t matter when matched to glorious singing. Soft, loud, high notes and higher, all were spun by Sierra with ease.

Spanish tenor Xabier Anduaga made his Met debut as Elvino this season. He has a solid lyric tenor that has all the notes Bellini needs. All he lacks is a brighter sound that would allow him to spin a gentler line. The dry sound aside, he was quite good as the jealous villager whom he portrayed as nasty and unfriendly. He said during the intermission interview that Elvino wasn’t a very likable character, which is how he was portrayed.

Alexander Vinogradov, mentioned above, has a beautiful lyric bass. He got as much as possible from his role. He also is a convincing actor, even allowing for the low acting bar set in this opera.

Sydney Mancasola was quite good in the seconda donna role of Lise. Also convincing was Deborah Nansteel as Amina’s stepmother. Nicholas Newton was appropriately surly given Villazón’s overly grim pseudo-Amish setting.

Maestro Riccardo Frizza has a good feel for bel canto opera. He supported the singers with sensitivity and helped realize the beauty of Bellini’s extraordinary melodies. But without a soprano of Sierra’s ability there is little reason to perform this opera. Two new productions of La Sonnambula over just 15 years is an extravagance the cash-strapped Met cannot afford.

The sets were largely devoid of furniture. Instead of houses, there were doors. Snow-capped peaks were in the background. An alter ego of Amina pranced about ostensibly on the mountain tops. Amina and her alter ego were twirling around in the cold, clad only in night gowns. Were this a serious opera they’d both be dead from TB before the final curtain. But both seemed impervious to snow and frost in this production.

The Met is doing six new productions this year. Three are almost certain to lose money. Only one of them will be on the HD telecasts this year. The final offering on May 30, 2026 will be Gabriela Lena Franks’s El último sueño de Frida y Diego.

La Sonnambula
Vincenzo Bellini | Felice Romani

Amina……….Nadine Sierra
Elvino ……….Xabier Anduaga
Rodolfo……….Alexander Vinogradov
Lisa……….Sydney Mancasola
Teresa……….Deborah Nansteel
Alessio……….Nicholas Newton
Notary………. Scott Scully

Conductor……….Riccardo Frizza
Production……….Rolando Villazón
Set Designer……….Johannes Leiacker
Costume Designer……….Brigitte Reiffenstuel
Lighting Designer………Donald Holder
Projection Designer……….Renaud Rubiano
Choreographer……….Leah Hausman
Video Director……….Gary Halvorson

T. cruzi is typically introduced into humans through the bite of triatomine bugs. When the insect defecates at the bite site, motile T. cruzi forms called trypomastigotes enter the bloodstream and invade various host cells. Within a host cell, the parasite transforms into a replicative form known as an amastigote, which undergoes multiple rounds of replication. The replicated amastigotes transform back into trypomastigotes, which rupture the host cell and are released into the blood. Trypomastigotes then disseminate throughout the body to various tissues, where they invade cells and replicate. Over many years, cycles of parasite replication and immune response can severely damage these tissues, particularly the heart and digestive tract.

The life cycle of the disease is shown in the figure below. As the label on it shows, it’s taken from the CDC.

The first description of the disease was made by Carlos Chagas in 1909 after examining a two-year-old girl with fever, swollen lymph nodes, and an enlarged spleen and liver. Upon examination of her blood, Chagas saw trypanosomes identical to those he had recently identified from the hindgut of triatomine bugs and named Trypanosoma cruzi in honor of his mentor, Brazilian physician Oswaldo Cruz.

Clinical Features

1. Acute Phase

The acute phase develops shortly after infection and lasts about 6 to 8 weeks. It is often mild or asymptomatic, particularly in adults, but may be severe in children.

Typical features include:

• Fever, malaise, anorexia, and lymphadenopathy
• Hepatosplenomegaly and mild myocarditis
• Romaña’s sign – unilateral painless swelling of the eyelid, a classic sign occurring when the parasite enters through the conjunctiva
• Chagoma – a localized swelling at the inoculation site

In severe acute infection, patients may develop acute myocarditis, pericardial effusion, or meningoencephalitis, which can be fatal, especially in infants. Parasitemia is high during this stage, making the diagnosis easier through direct detection of trypomastigotes in blood.

2. Indeterminate (Latent) Phase

After the acute phase, most patients enter an indeterminate or asymptomatic chronic phase, which can last for decades or even a lifetime. During this period, no clinical manifestations are present, but serologic tests remain positive. The parasite persists in low numbers in tissues, and gradual organ damage may silently progress. Approximately 60–70% of infected individuals remain in this indeterminate state permanently.

3. Chronic Phase

The chronic phase manifests years or decades after initial infection and is characterized by cardiac and gastrointestinal complications, which reflect destruction of autonomic ganglia and smooth muscle as well as myocardial fibrosis.

Cardiac involvement (Chronic Chagasic cardiomyopathy):
This is the most serious and life-threatening manifestation. Key features include:

• Cardiomegaly and progressive heart failure
• Arrhythmias and conduction defects (especially right bundle branch block)
• Apical aneurysm of the left ventricle
• Thromboembolism, leading to stroke or pulmonary embolism
• Sudden cardiac death, often due to ventricular arrhythmia

Gastrointestinal involvement:
Destruction of autonomic nerves in the digestive tract leads to megasyndromes, including:

• Megaesophagus – dysphagia, regurgitation, and malnutrition
• Megacolon – chronic constipation, abdominal distension, and risk of volvulus

These complications are prominent in regions such as Brazil and Bolivia.

Diagnosis

Diagnosis depends on the disease stage:

• Acute phase: detection of T. cruzi trypomastigotes in peripheral blood via microscopy or PCR.
• Chronic phase: detection of antibodies to T. cruzi by ELISA, indirect hemagglutination, or immunofluorescence tests.
  Additional studies such as EKG, echocardiography, barium swallow, or colonic imaging assess organ involvement.

Treatment

Treatment is most effective in the acute phase and in congenital infections. The two principal antiparasitic drugs are:

• Benznidazole
• Nifurtimox

Both are given for 60–90 days. They can reduce parasitemia and delay disease progression, though they may cause significant side effects. In the chronic phase, therapy focuses on managing complications—using antiarrhythmics, pacemakers, anticoagulants, and surgical interventions for gastrointestinal megasyndromes.

Prevention and Control

Because no vaccine exists, prevention relies on vector control and screening:

• Insecticide spraying to eliminate triatomine bugs
• Housing improvements to reduce insect infestation
• Screening of blood donors, organ donors, and pregnant women in endemic areas
• Health education campaigns to promote awareness and hygiene

These efforts, particularly in Latin America, have significantly reduced transmission in recent decades.

Chagas disease remains one of the most important parasitic diseases in the Americas, affecting millions and causing chronic cardiac and gastrointestinal morbidity. It ranges from asymptomatic infection to severe heart failure or digestive obstruction, reflecting the parasite’s capacity for lifelong persistence and tissue damage. Early detection and treatment, combined with sustained public health efforts, remain the cornerstone for controlling and eventually eliminating this serious tropical disease.

Chagas disease in the United States is an increasingly important public health concern, though it remains underrecognized and underdiagnosed. The Centers for Disease Control and Prevention (CDC) estimates that there are now more than 300,000 people living with Chagas disease in the U.S., most of whom were infected in endemic regions of Mexico, Central America, or South America before migrating north. However, locally acquired cases have also been documented in Texas, Arizona, California, Louisiana, and other southern states, demonstrating that transmission is possible within this country.

The insect vector (triatomine bugs) is native to parts of the southern United States. Over 30 species have been identified, and at least 11 species have been found naturally infected with T. cruzi. Most reside in wild or peridomestic environments, such as woodpiles, rodent nests, dog kennels, or chicken coops.

Most U.S. cases are chronic infections detected incidentally during blood donation screening, prenatal testing, or evaluation for cardiac disease. Clinical findings mirror those seen elsewhere.

Chagas disease in the United States is no longer a foreign problem. Although most cases are imported, domestic transmission is possible, and thousands of infected individuals remain undiagnosed. The U.S. faces a significant public health challenge: identifying and treating those already infected, preventing congenital transmission, and monitoring potential local spread. Increasing physician education and routine screening in at-risk populations are essential steps toward controlling this neglected tropical disease within the borders of the US.

My sources for the above article are:

1. The CDC
2. The World Health Organization
3. Pan American Health Organization (PAHO)
4. U.S. National Library of Medicine
5. Wikipedia Article on Chagas Disease
6. ChatCPT

He made his debut at the Metropolitan Opera as Rinuccio in Gianni Schicchi also conducted by Levine. He went on to give 208 performances at the Met. He also regularly appeared at the Vienna State Opera. His Met career was interrupted for seven years (1990-1997) due to personal issues combined with severe stage fright, which led to numerous cancellations at other companies. He is now retired and devotes much of his time to teaching.

Shicoff’s voice at his peak was a beautiful lirico-spinto that was best employed in the standard Italian and French repertoire. His vocal mechanics were excellent and he was able to convey the full emotional content of the music he sang. He had a major career and was clearly one of the best tenors of the last quarter of the previous century. Were it not for the personal problems, which need no further discussion here, he might have ranked as high as Richard Tucker among American tenors.

I only heard him in performance one time – as Eleazar in La Juive. He was outstanding as he is on the excerpts below. First, three arias from Massenet’s Werther. The role was especially suited to Shichoff’s voice; he sang it often.

‘O Nature, pleine de grâce’ is in Act 1. Werther expresses his feelings of love and wonder by addressing nature in a moment of deep, romantic contemplation.

‘Oui! Ce qu’elle m’ordonne’ is in Act 2. It is part of a passionate monologue where the poet Werther declares his love for Charlotte and his willingness to do anything for her, despite her being married.

‘Pourquoi me réveiller?’ is the opera’s most famous number. Every tenor sings it in recital or recording, even if the opera is not part of the repertoire. The aria addresses unrequited love, despair, and death. It expresses Werther’s intense emotion and his feeling of being broken by love.

Another Massenet aria – ‘Ah! Fuyez, douce image’. The Chevalier Des Grieux has taken religious vows in despair over losing Manon to a richer and older man. He relives memories of her.

Gounod’s Faust was the first opera ever performed at the Metropolitan Opera. It was done there so often that the house acquired the nickname the Faustspielhaus. It’s not done as frequently by the New York company as it was in the past and has dropped to eighth place on the list of most frequently performed operas. ‘Salut! demeure chaste et pure’ occurs in Act 3. Faust idealizes Marguerite as a pure child of nature.

The last French selection is from La Juive. It was recorded in performance in Vienna. It was this production that the Met borrowed for its revival of the opera with Shicoff in the leading role. The great aria ‘Rachel, quand du seigneur’ is the main reason to attend a performance of Halevy’s five act French grand opera. In the aria the Jewish goldsmith Eleazar does not want to sacrifice his adopted daughter Rachel to his hatred of Christians, and renounces his revenge. She’s really the long-lost daughter of the Cardinal Brogni. However, when he hears the cries from a pogrom in the streets, he decides that God wants him to bear witness in death with his daughter to the God of Israel. Shicoff’s singing gets everything there is from the aria.

The only reason a production can cast a star tenor as Macduff in Macbeth is the Act 4 aria ‘Ah, la paterna mano’. It’s one of Verdi’s finest. Apart from this number the tenor doesn’t have a whole lot more to do.

‘Fontainebleau forêt immense’ is the tenor aria in Act 1 of the original French production of Verdi’s Don Carlos. In versions in which Act 1 is omitted, the tenor aria is moved to the new first act.

The last Verdi aria is ‘Parmi veder le lagrime’ from Act 2 of Rigoletto. Shicoff sings the deceptively difficult aria with ease and style.

Finally, the two tenor arias from Tosca. ‘Recondita armonia’ followed by ‘E lucevan le stelle’.

Sierra has all the vocal bells and whistles necessary to realize Belini’s sleepwalking canary. She is the reason for this production. Anduaga, on the other hand, was a bit of a disappointment. Not that he was bad, but rather that he wasn’t as good as the hype generated about his appearance. One was expecting the resurrection of Giuseppe Di Stefano or at least the equivalent of Rolando Villazon before his vocal collapse. Villazon, interestingly, directed this new production. Anduaga’s voice had little sheen and seemed somewhat muffled. He made little of the lyrical simpleton that is Bellini’s hero. Elvino is on an IQ par with Donizetti’s Nemorino, Anduaga’s debut role at the Met in 2023. I’ll withhold final judgment until after the telecast of the opera on October 18.

If you would hear the role of Elvino sung to perfection, listen to Raúl Giménez singing recorded during a live performance made in performance more than 20 years ago.

Alexander Vinogradov has a light lyric bass and was fine as Count Rodolfo. Sydney Mancasola and Deborah Nansteel made as much as possible out of Lisa and Teresa, respectively. Conductor Riccardo Frizza kept everybody together. There’s little else for the conductor to do in this opera which is solely built on the quality of its singers. A detailed review will describe the production after the upcoming HD telecast.