Ebola virus disease

Can This Thumb Test Tell If You Are At Increased Risk Of A Hidden Aortic Aneurysm?

All the parts of our bodies share an inherent connectivity. This goes much further than "the foot bone's connected to the … leg bone". For instance, both hands and feet are connected to a constantly flowing bloodstream, and a nerve network that makes their muscles kick.

So what about the connection recently proposed by some news outlets regarding a simple test involving your palm and thumb? Could it really help diagnose a silent, yet potentially serious problem?

An aneurysm is what we're referring to here. This is a ballooned segment of an artery – the vessels that supply oxygenated blood to your body tissues. Aneurysms may cause no problems, but if they grow larger, they can weaken, burst and bleed. This is bad enough in most arteries, but imagine if the artery involved were the biggest in your body?

The vessel in question is the aorta. Aortic aneurysms can develop slowly and insidiously, without yielding any knowledge that they are evolving, since they may not trigger any symptoms.

Indeed, they may not become identifiable until they're starting to leak. By this stage, the threat to life from arterial rupture is severe.

Any test that can pick up an aneurysm before it gets to this danger point has great implications. Namely, so the defect can be closely monitored and repaired if needed.

So, is there a clinical basis for this proposed test? And what does it involve?

The thumb-palm test

The original paper regarding the problem dates to 2021. A research group in the US recognised that some people with aortic aneurysms demonstrated a sign in their hands when asked to cross their thumb across a flattened palm. A positive test was seen when the thumb extended all the way across the palm, protruding to the other side.

A link could be made between this finding and the presence of a connective tissue disorder, where joints and ligaments are lax and loose, and might lead to a positive test. Some connective tissue disorders, including Marfan syndrome, are known to be associated with developing aneurysms, so this observation made sense.

The findings were that a positive test was associated with a high likelihood of an aneurysm being present in the ascending portion of the aorta as it leaves the heart.

However, it's important to note that the landmark paper examining the relationship looked at 305 patients. Of these, ten showed the positive sign, so the sample size could have affected the results.

That's not to say that this test lacks credibility, but it needs to be tested on more patients first.

And it's not the only example of a test used in medical practice that is not perfect.

What makes a good test?

In medicine, we ideally want to use tests that accurately spot diseases without missing them. We also want those that don't misdiagnose patients, and are specific to certain conditions. We call these important parameters the sensitivity and specificity. Ideally, both should be as high as possible for a test to be considered a gold standard.

In reality, there are many tests we use that lack sensitivity or specificity. Take prostate-specific antigen (PSA) for instance – a simple blood screening test available to screen for prostate cancer. If the PSA comes back raised (and this is variable according to age) one of the underlying diagnoses might be prostate cancer.

But it also might be an enlarged or inflamed prostate, or a urinary tract infection. Or recent sexual intercourse. Or indeed, (but more speculatively) cycling before the test.

Many factors aside from cancer can cause a raised PSA, making the test lack specificity. PSA can also sometimes be normal in patients with prostate cancer, which means it lacks sensitivity.

This is why doctors have to use test results alongside other clues, such as examining the prostate to see if it is enlarged and craggy to the touch – altogether more suggestive of cancer.

Like PSA, what is known about the thumb-palm test shows it has to be interpreted correctly. Those with positive tests do not always have an aortic aneurysm. And having a negative test doesn't automatically exclude one. It also needs to be performed correctly: the palm must be flat, not folded, to prevent a false positive test.

But what does this all mean for detecting aortic aneurysms while more research is carried out? Perhaps we should be considering what is known about them.

We know that this condition is associated with high blood pressure, high cholesterol and smoking – so identifying and treating risk factors is important.

Equally important is scanning the aorta of those at-risk groups; those with certain connective tissue disorders or with a family history of aortic aneurysms.

The thumb-palm test has yet to be incorporated into clinical practice, but further research looking at larger patient populations might allow it some more credence. In the meantime, we must rely on what we do know, to detect them as early as possible, and monitor them lest they become dangerous.

ER Doctor Claims Simple Thumb Test Can Tell If You'll Suffer A Deadly Ruptured Artery... But Is He Right?

Emergency medicine physician Dr Joe Whittington sent the internet into a frenzy this week when he shared a simple exercise he said could be a sign you have a silent dangerous heart condition. 

The test, which was coined the thumb-to-palm test by Yale cardiologists, has people lay their hand flat on a table with their palm up or hold it out in front of them and reach their thumb across their palm. 

If the thumb protrudes off the opposite side of the hand, Dr Whittington said you have a 98 percent chance of having an aortic aneurysm - a dangerous bulge that could burst in the artery that carries blood from the heart. 

The ER doctor claimed the far reach of your thumb could be a sign you have a collagen deficiency, which could lead to dangerous swelling in your arteries. 

'Studies have shown that while not everyone with an aortic aneurysm has a positive test, those with a positive test have a 98 percent chance of having an aneurysm,' the California-based doctor said. 

But just as soon as it went viral, Dr Whittington's post vanished and it appears to have been deleted from his TikTok account, prompting people to question whether what he shared was correct.

How to perform the test: Hold your hand up as if you're telling someone to stop or lay your hand flat on a table, palm up (1). With your palm flat, stretch your thumb as far as you can across it, towards your pinky finger. If your thumb reaches the middle of the palm (2) that is normal. However, if it stretches past the edge of your hand (3), researchers say this may be a sign of a collagen disorder, which could increase your likelihood of developing aneurysm

Dr Whittington deleted his original video. In it he said those with a positive thumb to palm test 'have a 98 percent change of having an aneurysm.'

Before it was deleted, however, it sent people into a panic. 

One TikTok user shared a video of herself trying the test, which saw her thumb hanging over the edge of her palm with the caption 'Should I be worried?' 

Another commented on the post: 'Oh great. Now I need another support group for my TikTok anxiety.' 

The science behind the test is complicated, according to Dr Muhammad Siyad Panhwar, an interventional cardiologist at Sanford Health. 

'There's no need for panic', he said in a TikTok responding to Dr Whittington.  

While it's true the palm to thumb test could be a sign that you have a collagen deficiency, it's not a confirmation that you definitely have an aneurysm, Dr Panhwar added. 

Collagen is a stretchy, supportive fiber that exists all over the body - and is particularly important in helping blood vessels hold their shape over time. 

If you are deficient in collagen, you could have weaker blood vessels, which are more at risk for ballooning out over time with stress, causing an aneurysm.

Certain collagen disorders have been linked to aneurysms of the ascending aorta, a particularly high-risk region because it's the main blood vessel that stems from the heart, meaning it gets a lot of wear and tear, Dr Kenan Yount, a cardiothoracic surgeon at the University of Virginia said in a video. 

Roughly eight and 10 people who have a ruptured aneurysm die before reaching the hospital, according to the NHS. And aortic aneurysm ruptures caused about 9,904 deaths in 2019, according to the latest data from the CDC. 

Dr Yount highlighted conditions like Marfan's syndrome, Ehler's-danlos and Loeys-Dietz syndrome. 

These conditions effect your aorta, but also manifest in other parts of your body - like in your joints. People with collagen disorders frequently have hypermobile, or extremely flexible, joints. 

The link between collagen disorders and blood vessel dysfunction is where the palm to thumb test comes in.

If you have an ascending aortic aneurysm that becomes large enough that it requires treatment, doctors sometimes implant a surgical mesh around the vessel to support it. 

It was developed in 2021 after cardiologists at Yale examined 305 patients that were already in the hospital for heart surgery. 

Of those, 93 patients were there for an ascending aortic aneurysm - meaning they had an aneurysm on the top of the blood vessel that protrudes from the heart. 

Ninety-eight percent of those 93 patients had a positive thumb to palm test, which could be what Dr Whittington based his claim on. 

'Our study showed that the majority of aneurysm patients do not manifest a positive thumb-palm sign, but patients who do have a positive test have a high likelihood of harboring an aneurysm,' study author Dr John Elefteriades, emeritus director of the Aortic Institute at Yale New Haven Hospital, said. 

Quarter of a million Americans die every year after being misdiagnosed in ER, federal study suggests 

A quarter of a million Americans die every year because they are misdiagnosed in the emergency room, a federal report suggests. 

Advertisement

This means the test could be a sign to check in with your doctor about your risk for developing aneurysms, but it isn't a diagnosis of an aneurysm, he said. 

And even if you do have a positive thumb to palm test and it turns out you also have an aneurysm, that's no reason to panic as not all aneurysms are emergencies, Dr Panhwar said. 

'This is not an emergency. These aneurysms typically grow very slowly and a lot of the time we just monitor them every year with ultrasounds or CAT scans,' he said in his TikTok. 

If your doctors determine your blood vessel is stretching into dangerous territory, they'll send you in for a five-hour surgery to support that part of your blood vessel with a flexible sleeve, similar to a garden hose. 

Recovery takes about four to six weeks.

If left untreated, an aneurysm can get so large the tension on the tissue causes the vessel to rip or burst, Dr Yount said, adding that, 'either of those scenarios could be life-threatening.' 

Symptoms of a ruptured aorta include a ripping sensation in the chest, severe back pain and dizziness. 

The best way to use this test, Dr Panhwar said, is to utilize the information gained from it.

If you have a positive palm to thumb test and a family history of a collagen disorder, you should check in with your doctor. 

He added: 'Don't worry, you're not going to die at night of a burst aneurysm. Just go talk to your doctor, that's all.'

Symptoms of a ruptured aortic aneurysm 

Many people who have an aneurysm have no symptoms, until they have a dangerous rupture or tear.

If it does tear, then blood will leak out of the injury, pooling in the chest cavity. 

At this point, patients usually report feeling a severe 'ripping'  pain in their chest and upper back- which persists until it's treated through surgery or stenting.

Source: Johns Hopkins 

Me And My Operation: Aortic Aneurysm

by ANGELA BROOKS, Daily Mail

The NHS undertakes 6,000 aortic aneurysm operations a year. Here, Hamish Duncan, 62, an electrical engineer who lives with his wife Pamela, a former nurse, in Linlithgow, West Lothian, tells how an emergency operation saved his life, and his surgeon explains the procedure.

THE PATIENT

The first time I knew something wasn't right was when I was walking my dog one morning. I felt this shallow ache in the base of my back, quite different to any backache I'd ever had.

I hadn't been ill in 15 years, but I phoned my GP and he told me to take painkillers. The pain just got worse and was throbbing just above my waistband in the front. It was so bad that late that night Pamela took me to the local health centre, where she was advised to get me to St John's, the local hospital.

By the time we got there, I felt I could have passed out with the pain. My shirt was saturated with sweat and my younger son, who had come with us, almost carried me in.

A doctor there recognised it was an aneurysm - a bulging of the aorta which can rupture - and phoned Edinburgh Royal Infirmary, who said they would have a team waiting to operate.

I was wrapped in tin foil and rushed by ambulance to the Royal Infirmary. By then, I was only semi- conscious. Mr Chalmers, the surgeon, came to see my wife and sons - they were both with her by then - and was very honest.

He said they knew the aneurysm had ruptured and I was bleeding internally, but they would have to open me up to discover where it was and then fit me with a graft. My chances of pulling through were 50-50.

The next thing I recall is coming round after the operation with Mr Chalmers leaning over me. He told me: 'You've done rather well.'

He said I had a good, strong heart but that it had taken a big jolt from the operation and it would take time before I was back to normal.

Two days later, I was moved from intensive care to a highdependency unit for four days, and then on to a normal hospital ward for almost a week.

Staff at the Royal Infirmary were excellent, and slowly I was weaned off all the tubes I was attached to. Each day, the physiotherapist would come and take me for small walks, building up to include stairs.

When I was discharged, Mr Chalmers told me he wanted me to try to build up my endurance so that I could walk two or three miles a day. Our dog couldn't believe his luck.

I've stopped smoking, which is imperative, but I'm still finding it hard. In February - five months after the operation - I went back to work part-time; now I'm back full-time.

The illness has been a blow to my confidence because I've never been in hospital before, but the only outward sign is a narrow scar across my stomach.

THE SURGEON

Mr Roderick Chalmers, consultant vascular surgeon at Edinburgh Royal Infirmary, says:

An aortic aneurysm is a balloonlike bulging of the aorta, which is the body's largest artery. The big danger is the risk of rupture when it gets too big - which was Mr Duncan's experience.

Fifty per cent of people with a ruptured aneurysm die before reaching hospital. Of those that make it, the average odds on surviving surgery are only 50-50, but here in Edinburgh, a centre of excellence, the survival rate is closer to 65 per cent.

It is a silent killer because patients may be symptom-free until it ruptures and becomes an emergency.

Aortic aneurysms overwhelmingly affect males - in their late 50s upwards.

No one knows the cause for sure, but smoking is implicated and it is associated with hardening of the arteries. We think an abnormality in the vessel walls leads to a weakness, which allows this ballooning over a period of time.

The abdominal aorta runs down the back of the abdomen, in front of the vertebral column.

The severe back pain associated with it is caused by the aneurysm pressing on the nerves coming out of the spinal column. The abdominal pain is caused by the tissue lining the abdomen (the peritoneum) becoming stretched and inflamed from the rupture.

The principle of the operation is to replace the segment of affected aorta with a graft made of a woven material, and to stitch it to normal artery above and below the aneurysm.

The high risks attached to this surgery come from clamping the aorta - the main blood supply to the lower half of the body, which can put the heart under huge strain.

The task of the vascular team is a fine balancing act. Patients can be bleeding massively and their blood pressure may have dropped so low that it is struggling to sustain their vital organs.

We have to calibrate their blood pressure so that it's high enough to maintain their organs - but not so high that it will cause further bleeding. Also, we don't want to delay getting the patient to theatre.

Once in theatre, I make the first incision horizontally just above the navel and siphon off any blood in the abdominal cavity. This we clean and store so it can be used if the patient requires a blood transfusion.

All the abdominal organs will probably be displaced by the aneurysm, which is sometimes as big as a football. We move aside the intestines and the liver, holding them with retractors, and siphon off any pooled blood.

Now we get control of the aorta just above the aneurysm by placing on it our first clamp. At the level of the tummy button the aorta divides into two arteries - the iliac arteries - one of which goes to each leg. I clamp both of these.

Our next step is to open up the aneurysm, which will look like a baggy balloon. On the inside wall, we shell out the layers of blood clot debris that will have built up over the years.

We don't actually remove the aneurysm: we recycle the sac to protect our graft, which looks like a piece of knitted tubing.

First we join the graft to the upper part of the aorta, stitching it around in a circle. We then do the same for the lower join.

Next, to make sure there are no leaks in our joins, we slowly release the lower clamp, allowing blood to come back up from the legs. Finally, we flush out the graft using a solution of saline and heparin, an anti-coagulant.

We have to release the clamps very gradually from each of the iliac arteries to ensure that the heart doesn't suddenly have a massive amount of work to do.

If the patient's feet are pink - a sign that blood is circulating properly - we check that blood pressure and pulse are close to normal and the graft is leak-free.

We then wrap the aneurysm sac around it and stitch it so the graft is totally hidden. The other abdominal organs have a propensity for sticking to artificial materials - which we don't want - and the sac prevents that.

Our last step is simply putting some stitches in the tummy.

Patients will be very carefully monitored in intensive care for about two days, then will go to a high dependency unit.

The long-term prognosis for aneurysm patients is excellent, but quitting smoking is vital.

An emergency ruptured aneurysm operation costs the NHS approximately £20,000, which includes up to two weeks in hospital.

{"status":"error","code":"499","payload":"Asset id not found: readcomments comments with assetId=111252, assetTypeId=1"}

---