Screening for type 1 diabetes: what would the U.S. Preventive Services Task Force recommend?

It has now been 15 months since the U.S. Preventive Services Task Force (USPSTF) last met. In the interim, several members' 4-year terms expired, and HHS Secretary RFK Jr. fired the two remaining Vice Chairs, leaving the USPSTF leaderless and without a voting quorum. Although much of the work of the Task Force occurs on conference calls in between scheduled meetings, no new recommendations can be debated or finalized in the current situation. Even if new members with appropriate qualifications are eventually appointed, the future of the USPSTF remains uncertain. So when a new study suggests that a screening test could be beneficial, clinicians and medical groups can only make their best guess about what the USPSTF might recommend based on the evidence.

Unlike prediabetes and type 2 diabetes, the USPSTF has never evaluated screening for type 1 diabetes in the general population. There are two major rationales for screening. First, a large percentage of persons are not diagnosed until they develop symptoms of diabetic ketoacidosis (DKA), a life-threatening situation that invariably requires hospitalization and frequently a stay in the intensive care unit. Second, a therapy exists that delays the onset of the disease in children determined to be high risk. Although the Centers for Disease Control and Prevention and expert groups recommend screening relatives of persons with type 1 diabetes with autoantibody tests, the vast majority of persons who are diagnosed have no family history.

The ideal type of study to establish the benefits and harms of screening for type 1 diabetes would be a randomized trial where participants were randomly assigned to screening or control groups and followed for important clinical outcomes such as DKA, diabetes complications, and mortality. But type 1 diabetes is not nearly as common as type 2, and thousands of participants would need to be followed for years to detect a statistically significant difference in outcomes. This large-scale study would require an investment of money and resources that no private or public funder has thus far been willing to support.

Instead, individual screening programs have been implemented in various locations around the world. Some are focusing on screening relatives of persons with type 1 diabetes, while others are screening the general population in primary care settings. One of the latter programs in Germany was established in 2015 and recently reported 10-year outcomes in a paper in JAMA. Out of more than 220,000 children screened, 590 (0.3%) had autoantibodies but no clinical symptoms. After 5 years, 36% of those with positive screens had progressed to clinical type 1 diabetes, representing 81% of all children who ultimately received this diagnosis. Of note, the progression rate was similar in children with and without a first-degree relative with type 1 diabetes.

Without a comparison group, we don't know how these children would have fared in the absence of screening. Did some of them avoid a traumatic hospitalization for DKA or receive therapy that gave them a few more years without clinical symptoms? Conversely, did they or their loved ones experience negative psychological effects from being a given an early diagnosis, particularly the 64% who had not progressed to clinical diabetes after 5 years? The researchers don't say. My guess is that the USPSTF would have deemed this study to be insufficient evidence to assess the balance of benefits and harms of screening all children for type 1 diabetes. Absent a formal evidence assessment, though, I suspect that many well-intentioned experts will push prematurely for screening to take place anyway - which is why the Task Force needs to be restored and reconvened without further delay.

Stopping an outbreak: hantavirus on the MV Hondius

Although an estimated two-thirds of international travelers will develop a travel-related illness, most fevers and respiratory symptoms have self-limiting causes. A notable exception was an outbreak of severe acute respiratory illness that afflicted 13 passengers and crew members (including the ship’s doctor) on the expedition cruise ship MV Hondius and caused three deaths. The first passenger to die most likely acquired the infection from a rodent in Argentina, where the MV Hondius departed on April 1, 2026. Reverse transcriptase polymerase chain reaction (RT-PCR) testing confirmed that the contagious illness was hantavirus cardiopulmonary syndrome caused by the Andes virus, which had previously shown person-to-person transmissibility in crowded social settings.

A 2002 American Family Physician article called hantavirus infection “a zebra worth knowing” because, although it is rare (fewer than 900 cases have been reported in the United States since 2023), prompt diagnosis in persons with early symptoms can be lifesaving. Outside of the Andes virus, hantavirus is acquired by exposure to saliva, urine, or feces of infected rodents, such as the deer mouse in the United States.

After an incubation period of up to several weeks, patients in the prodromal phase of the illness develop fever and myalgias, lasting 3 to 5 days. Characteristic laboratory findings include thrombocytopenia, left-shifted leukocytosis, circulating immunoblasts, and hemoconcentration. The cardiopulmonary phase is heralded by the acute onset of hypotension, pulmonary edema, tachypnea, and progressive hypoxia, usually requiring mechanical ventilation within 24 hours. No specific treatment is available. Despite supportive care, the case fatality rate of hantavirus cardiopulmonary syndrome approaches 40%.

On May 18, 2026, the Centers for Disease Control and Prevention issued a health alert for US clinicians and health departments about when to consider testing patients for hantavirus infection. It is thought that transmission of Andes virus occurs only in the symptomatic phases; therefore, at least 65 US passengers and others with possible Andes virus exposures are being monitored at home by state health departments or in the 20-bed National Quarantine Unit at the University of Nebraska Medical Center, though many of the latter are being forcibly prevented from going home.

Despite a superficial resemblance to the early days of the COVID-19 pandemic—a fatal respiratory illness spread rapidly on a cruise ship while political leaders and public health authorities assert that the risk to the general public is low—Andes virus will not become the next pandemic. (After being cleaned and disinfected, the MV Hondius resumed passenger operations on June 13, 2026.) However, the outbreak response highlighted gaps in global public health preparedness that have widened since the United States withdrew from the World Health Organization (WHO) in early 2026. A fatal outbreak on an oceangoing vessel is an international problem by definition, but efforts by various countries to contain it have been halting and inconsistent. In a JAMA commentary, Dr. Attila Hertelendy and colleagues asserted:

The principal vulnerability exposed by the Hondius outbreak lies not in sustained [viral] transmission, but in delayed recognition, fragmented authority, and inconsistent public health implementation across jurisdictions. … WHO can coordinate information sharing, issue technical guidance, and recommend public health measures, but it cannot compel states to permit disembarkation, harmonize quarantine protocols, or share responsibility for exposed travelers.

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This post first appeared on the AFP Community Blog.

When emotions matter more than evidence: preventing deaths from firearms

In 2019, after another of the horrific mass shooting events that most Americans have become numb to but are far less common in other developed countries, I was asked to participate in a panel presentation on "Gun Violence as a Public Health Issue" at the Family Medicine Education Consortium's annual meeting. I worked hard to make my presentation as non-ideological as possible, mustering slide after slide of statistics showing the rise in firearm-related injuries and deaths since the turn of the century from many peer-reviewed studies. I acknowledged, though, that as with many other public health issues, no number of facts and figures would be completely persuasive. Gun violence is an issue where emotions matter more than evidence. For many, firearm ownership ensures freedom from tyranny, and government restrictions on purchasing guns, however reasonable, represent threats to personal liberty.

The following year, homicides and suicides from firearms surpassed motor vehicle accidents as the leading cause of death in children and adolescents for the first time, and an updated analysis found that the firearm-related death rate in this group increased by 3.9% from 2020 to 2023. For perspective, in 2023, guns killed 4455 children, while Covid-19 infections accounted for 125 children's deaths in 2023 and 547 deaths at the pandemic's peak in 2021. This is why it is as essential for physicians to provide counseling on firearm injury prevention during well-child visits as counseling regarding Covid-19 and other recommended vaccines.

A recent cross-sectional study in JAMA Network Open examined associations between state firearm laws and firearm-related suicides from 1976 to 2024. The investigators focused on 6 types of laws involving handgun permits, waiting periods for firearm purchases, concealed carry licenses, minimum age requirements, extreme risk protection orders, and permits for gun dealers. They found that states that required handgun permits, waiting periods, and/or concealed carry licenses had lower firearm suicide rates, and states with all 3 laws had 25% lower rates than states with none.

Compared to these legislative interventions, individual clinicians have less to offer. The U.S. Preventive Services Task Force found insufficient evidence that screening adults for suicide risk prevents suicides, and it isn't certain that counseling gun owners about safe storage practices (using trigger locks, gun safes, storing ammunition separately) makes a difference, either.

As for gun homicides, public health interventions aimed at resolving conflicts without resorting to violence have shown positive results in Baltimore, Maryland, where gun violence is treated as a contagious disease and "violence interrupters" work diligently to defuse small disputes before they involve firearms. Critically, preventing violence also involves recognizing and addressing its structural causes:

Baltimore’s first comprehensive violence prevention plan takes public safety beyond police, prosecution, and prison by working closely with community groups to focus on prevention and support for those most affected by the violence. ... Community organizations, some partially funded by the Mayor’s Office, connect people to education and life coaching. They help get documents like IDs, birth certificates, and Social Security cards, and they help expunge criminal records, making it easier to get jobs. They pay energy bills and fill gas tanks; they offer emergency relocation, financial stipends, transitional employment support, drug treatment—even helping people to reconnect with their families.

Lancaster Medical Heritage Museum's Object of the Month: Ether Mask

I serve on the Board of Directors of the Lancaster Medical Heritage Museum, and we have inaugurated an "Object of the Month" feature to highlight interesting items from the museum's collections. Here is the one for June.

Before modern anesthesia machines, surgeons relied on devices like this historic ether mask to safely administer anesthetics during surgery.

Used from the late 19th century through the mid-20th century, ether masks allowed physicians to administer ether or chloroform through inhalation by dripping the liquid onto layers of gauze stretched across a metal frame. As the anesthetic evaporated, patients inhaled the vapor, allowing surgeons to perform increasingly complex procedures.

Prior to the development of ether masks, anesthesia was often administered using simple cloth cones or towels soaked in ether, methods that were far less controlled and could cause irritation or burns.

This month’s featured object highlights the evolution of anesthesia and the dramatic changes it brought to medicine and surgery. Ether and chloroform were widely used during the Civil War, World Wars I and II, and the Korean War, transforming battlefield and hospital care alike.

You can see this historic ether mask on display at the museum.

Research provided by Dr. Stephen Olin.

How recent Paxlovid studies explode Covid-19 mortality myths

In December 2021, at the height of the pandemic, the US Food and Drug Administration (FDA) granted emergency use authorization for oral nirmatrelvir-ritonavir (Paxlovid) for outpatient treatment of mild to moderate COVID-19 in adults at high risk of progression to severe disease. In February 2022, a randomized trial of 2,246 unvaccinated adults with COVID-19 reported that starting Paxlovid within 5 days of symptom onset reduced the relative risk of hospitalization or death by 89%, with 13 deaths occurring in the placebo group and none in the intervention group. These results led to expanded access to the drug via pharmacist prescribing and eventually resulted in full FDA approval in May 2023. An American Family Physician article on outpatient COVID-19 management includes clinical recommendations to consider treating high-risk adults with Paxlovid to prevent hospitalization and death.

Does Paxlovid still have value in a population with widespread immunity to COVID-19 from vaccination and prior infection? In a subsequent placebo-controlled trial of the drug with 1,296 patients (one-half vaccinated and with a risk factor for severe disease and one-half unvaccinated with no risk factors) recruited during the Delta and Omicron waves, no significant differences in symptom duration or likelihood of hospitalization or death were found.

Two open-label trials of Paxlovid in the United Kingdom and Canada that collectively enrolled 4,000 participants between April 2022 and September 2024 recently published their findings in a combined paper. Adults older than 50 years and younger adults with high-risk conditions (eg, obesity) were eligible; 98% had received a COVID-19 vaccine. Overall, less than 1% of participants were hospitalized, with no statistical differences between groups, and no one died. Outcomes for immunocompromised patients were similar; in the United Kingdom study, only 3 of 296 were hospitalized, with no benefit of Paxlovid. Although participants in the treatment group appeared to recover several days earlier than did those in the control group, the study’s lack of blinding indicates that symptom improvement may represent a placebo effect rather than a true benefit.

In a related commentary, Dr. Jeremy Faust observed: "The severe event rate (i.e., hospitalizations and deaths) in this paper was so low that it’s difficult to imagine any new antiviral will be able to show such a benefit for the foreseeable future. … So, the next big antiviral against Covid-19 will likely never be shown to prevent deaths or hospitalizations—which … is actually good news."

Why good news? A pernicious myth about the early years of the Covid-19 pandemic is that most people died "with" rather than "from" the infection, even though there were over a million excess deaths in the U.S. and more than 22 million worldwide from 2020-2023 compared to pre-pandemic mortality rates. A related myth is that the older adults who died from Covid-19 would have died from something else soon anyway. A recent analysis of data from the United Kingdom showed that in fact, the "mortality displacement" (death earlier than expected) due to Covid-19 was quite significant: adults over 65 lost a median of 4 to 5 years of life, and two-thirds of women aged 65 to 74 years likely would have survived 5 years or more if they had avoided the infection. The reason for Paxlovid's decreased effectiveness isn't that the drug suddenly stopped working; it's that vaccine and infection-derived immunity have made the very worst outcomes of Covid-19 thankfully uncommon.

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A previous version of this post appeared on the AFP Community Blog.

Screening for testicular cancer is ineffective

In adolescent and young adult males, palpation of the testicles for signs of cancer has traditionally been part of the preparticipation sports physical or well-child examination. Unlike most malignancies that predominantly affect older adults, testicular cancer is most commonly diagnosed between 15 and 34 years of age. Nonetheless, screening for testicular cancer has long been something I have discouraged my students and residents from doing. The rationale is twofold: it's rare, so screening will lead to many false positives and unnecessary evaluations; and more importantly, it's curable even at advanced stages, so earlier detection provides little to no incremental benefit. These were the reasons why in 2011, the U.S. Preventive Services Task Force (USPSTF) reaffirmed its previous recommendation against testicular cancer screening, based on an evidence review that I co-authored that found no new evidence to change this conclusion.

Others have dissented over the years. They argue that young men are among the least likely to visit a doctor and most likely to ignore early symptoms of testicular cancer. American cyclist Lance Armstrong was famously diagnosed with stage 3 testicular cancer at age 24 after ignoring the warning signs for months, having become used to intermittent groin pain and fatigue from grueling hundred-mile training rides up the sides of mountains. (After surgery and chemotherapy, Armstrong not only survived, but went on to win the Tour de France a record seven consecutive times before having his titles rescinded for doping.)

The most salient argument against the USPSTF's "D" recommendation is that until recently, no one had actually studied the outcomes of a sizable real-world program of testicular cancer screening. Consequently, this critique stated, the recommendation grade should be "I" (insufficient evidence). In fact, I have been concerned that the Task Force's 2018 reversal on prostate cancer screening (from "D" to "C" in men age 55 to 69 years) foreshadowed a similar change of heart on testicular cancer the next time they decided to revisit the topic.

A recently published paper appears to have closed the door on that possibility. A team of researchers performed a retrospective cohort study of more than 300,000 Israeli males age 16 to 21 years who had testicular examinations between 2012 and 2021 as part of medical screening evaluations for mandatory military service. All participants were followed for the duration of their service (generally 3 years). 43 testicular cancers developed during the study (incidence rate of 3.67 per 100,000 person-years); even though the vast majority were diagnosed clinically rather than through screening, 86% were stage 1. Of the 6 cancers determined to have been present at the initial exam (diagnosed within 6 months), screening detected 4 at the cost of 804 false positives. More than 75,000 screening exams, 176 ultrasound scans, and 112 urologist visits were required to detect a single cancer. The researchers concluded that "the low sensitivity, high number needed to screen, frequent unnecessary evaluations, and low incidence of testicular cancer suggest that routine screening of asymptomatic adolescents is ineffective."