LitCovid-sentences  

PMC:7780429 / 1630-30213 JSONTXT 3 Projects

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Id Subject Object Predicate Lexical cue
T18 0-12 Sentence denotes Key messages
T19 14-55 Sentence denotes What is already known about this subject?
T20 56-207 Sentence denotes During the increase in COVID-19 cases, health authorities established the mandatory use of Personal Protective Equipment (PPE) by health professionals.
T21 208-421 Sentence denotes Face masks are recommended as a simple barrier to help prevent respiratory droplets from travelling through the air and reaching others when the person wearing the mask coughs, sneezes, speaks or raises his voice.
T22 422-480 Sentence denotes In ‘front-line’ work, wearing masks can be time consuming.
T23 481-604 Sentence denotes Although highly effective masks are generally well tolerated, some health problems have been reported, including headaches.
T24 606-632 Sentence denotes What are the new findings?
T25 633-828 Sentence denotes The appearance of ‘de novo’ headache is associated with the use of filter masks and is more frequent in certain health workers, causing a greater occupational, family, personal and social impact.
T26 829-1005 Sentence denotes The pathogenesis of ‘de novo’ PPE-associated headaches could possibly have several aetiological considerations, including mechanical factors, hypoxaemia, hypercapnia or stress.
T27 1007-1086 Sentence denotes How might this impact on policy or clinical practice in the foreseeable future?
T28 1087-1348 Sentence denotes Given that the use of these devices will tend to become widespread due to the implications of the pandemic, we believe it is important to promote prevention and protection strategies that guarantee the safety of workers, without affecting their quality of life.
T29 1349-1466 Sentence denotes Better strategies may be needed to design various types of PPE and reduce their exposure time for healthcare workers.
T30 1467-1639 Sentence denotes Through engineered solutions, the next-generation protective mask will have an improved design with an emphasis on tolerability and consequently be less prone to headaches.
T31 1641-1653 Sentence denotes Introduction
T32 1654-1752 Sentence denotes In December 2019, a new coronavirus, SARS-CoV-2, started an outbreak in the Chinese city of Wuhan.
T33 1753-2156 Sentence denotes In January 2020 its clinical picture was defined as a disease associated with COVID-19.1 2 This outbreak evolved into a pandemic and on 24 May 2020, 216 countries had been affected, 5 206 614 cases had been confirmed worldwide and 337 736 deaths.3 In Spain, there are 233 037 cases, and 27 940 patients have lost their lives.4 In the region of Extremadura, 3047 cases and 506 deaths have been reported.5
T34 2157-2334 Sentence denotes During the increase in cases of COVID-19 in our environment, the health authorities established the mandatory use of Personal Protective Equipment (PPE) by health professionals.
T35 2335-2433 Sentence denotes This PPE consists of a protective suit, surgical gloves, protective goggles, shield and face mask.
T36 2434-2763 Sentence denotes In the case of face masks, they must be highly effective, with type FFP2 (filtering face pieces) (in Europe), N95 (USA) and KN95 (China) recommended.6 There are other types of masks (surgical masks or FPP1 among others), of lesser effectiveness, which are used by healthcare personnel who is not in direct contact with COVID-19.7
T37 2764-3585 Sentence denotes In ‘front-line’ work, the use of masks can be very prolonged.8 Although, in general, highly effective masks are well tolerated, some problems have been reported, such as: general discomfort; decreased visual, auditory or vocal capacity; excessive heat or humidity; facial pressure; skin lesions; itching; fatigue; anxiety and claustrophobia.9 Another effect described in the 2003 SARS epidemic was headache, whose prevalence reached 37.3% of the health personnel studied.10 This headache can be related to mechanical factors, the presence of hypoxaemia and hypercapnia or to the stress associated with mask use.11 12 Our aim is to demonstrate if there is an association between the appearance of ‘de novo’ headache with the type of mask and its time of use, as well as the impact of this headache on health professionals.
T38 3587-3593 Sentence denotes Method
T39 3594-3775 Sentence denotes The study was conducted in the health area of a tertiary hospital, where our health system in the COVID-19 period urged health professionals to use PPE during contact with patients.
T40 3776-3972 Sentence denotes These protective systems were mandatory among health workers, both in high-risk areas, and in general medical wards, central hospital radiology, and diagnostic imaging areas or outpatient clinics.
T41 3973-4084 Sentence denotes This involved the use of different types of more or less tight-fitting masks, and sometimes glasses or screens.
T42 4085-4246 Sentence denotes Using a self-administered questionnaire addressed to health workers in our health area, we carried out a cross-sectional study during the first week of May 2020.
T43 4247-4396 Sentence denotes In the previous month, the number of admissions for COVID-19 was very high and attendance protocols required the use of these devices by all workers.
T44 4397-4794 Sentence denotes Following the International Classification of Headache Disorders, Third Edition (ICHD-3) criteria,11 we define ‘de novo’ headache: ‘when a new headache occurs for the first time in close temporal relationship to use PPE, even when the headache has the characteristics of a primary headache (migraine, tension type of headache, cluster headache or one of the other trigeminal autonomic headaches)’.
T45 4795-5943 Sentence denotes The questionnaire collected the following information: (1) demographics; (2) medical history, including SARS-CoV-2 infection; (3) type and pattern of mask use: surgical masks versus self-filter masks of particles and liquid aerosols (FFP), average number of hours of use per day and use of other protective devices (glasses or screens); (4) frequency and characteristics of pre-existing primary headache (changes in headache frequency, attack duration and frequency, as well as drug use and response); (5) the main variable of the study was personal opinion about the presence of a new headache in the period in which these protective systems were mandatory; (6) presence of other symptoms potentially associated with the use of facial protection equipment; (7) we evaluated the self-perceived impact of the presence of new-onset headache using the Likert scale on social, occupational, family and personal aspects; (8) we also evaluated the self-perceived impact that headache conditions have on the performance of work activities and (9) lastly, we analysed self-perceived work stress by means of the Psychosomatic Problems Questionnaire (PPQ).13
T46 5944-6070 Sentence denotes The questionnaire was written after an analysis of the literature and a thorough reflection on the problem to be investigated.
T47 6071-6222 Sentence denotes It included a request for voluntary collaboration, information on the reason for the survey, instructions for completing the questionnaire and consent.
T48 6223-6275 Sentence denotes The average time taken to complete was about 20 min.
T49 6276-6342 Sentence denotes The information collection procedure chosen was the online survey.
T50 6343-6500 Sentence denotes The survey was scheduled to be conducted over 5 consecutive days, between 1 May 2020 and 6 May 2020, with the data collected referring to the previous month.
T51 6501-6655 Sentence denotes The data collected in the study respects the anonymity of the subject and there is no possibility of access to any personal information of the individual.
T52 6656-6816 Sentence denotes The data analysed are restricted to the study investigators, health authorities and the Ethics Committee, when required, in accordance with current legislation.
T53 6818-6838 Sentence denotes Statistical analysis
T54 6839-6986 Sentence denotes Prior to the analysis of relationships between variables, descriptive analyses of the different areas that make up the study have been carried out.
T55 6987-7160 Sentence denotes These descriptive analyses include percentage distributions of the different categories of the analysed variables and, in the case of quantitative variables, average and SD.
T56 7161-7483 Sentence denotes These same analyses, shown as a cross between variables by means of contingency tables or comparison of averages, have also been elaborated as a preamble to the statistical tests that have been carried out to corroborate if there is a relationship between different variables, thus showing the hypotheses to be contrasted.
T57 7484-7591 Sentence denotes Depending on the nature of the variable and the distribution of the sample, different tests have been used.
T58 7592-7743 Sentence denotes We used the Χ2 test to contrast whether there is independence between two categorical variables using a contingency table when the data are not paired.
T59 7744-8025 Sentence denotes For the analysis of the predictive factors with the appearance of a ‘de novo’ headache, we used binary logistic regression methods by steps backwards, to maximise sensitivity; variables with a univariate association of p<0.200 were included as candidates in the multivariate model.
T60 8026-8245 Sentence denotes To measure the relationship between the different variables in the study, statistical tests with a 95% significance level were used as an acceptance threshold for the hypotheses to be tested, that is, a p value of 0.05.
T61 8246-8348 Sentence denotes All statistical analyses were performed using the SPSS V.25.0 statistical package program for Windows.
T62 8350-8357 Sentence denotes Results
T63 8358-8520 Sentence denotes A total of 306 health professionals and other health workers participated in the study, 62 men (20.3%) and 244 women (79.7%), with an average age of 43 years (SD:
T64 8521-8531 Sentence denotes 11; range:
T65 8532-8539 Sentence denotes 23–65).
T66 8540-8713 Sentence denotes Of these, 129 (42.2%) participants were physicians, 112 (36.6%) nurses and the rest, 65 (21.2%) other health workers (assistants, guards, technicians, administrative staff).
T67 8714-8880 Sentence denotes With regard to the work shift, 89 (34.1%) worked in the morning and on duty, 91 (34.9%) at morning, afternoon and night shifts, and 81 (31.0%) in morning shifts only.
T68 8881-9052 Sentence denotes The surgical mask was used by 208 (79.7%) of those surveyed, and the filter mask (FFP2 or KN95) was used by 53 (20.3%), with no difference in the mean time of use 7.0 (SD:
T69 9053-9075 Sentence denotes 2.3) hours vs 6.7 (SD:
T70 9076-9096 Sentence denotes 2.5) hours, p=0.289.
T71 9097-9214 Sentence denotes A total of 46.4% (121) reported not habitually using other facial protection devices such as glasses, screens or PPE.
T72 9215-9291 Sentence denotes The rate of confirmed SARS-CoV-2 infection in the study population was 4.6%.
T73 9292-9549 Sentence denotes The most frequently reported diseases in the total sample in order of frequency were: allergy, 34 (13.0%); thyroid diseases, 28 (10.7%); anxiety, 26 (10.0%); high blood pressure, 18 (6.9%); asthma, 17 (6.5%); dyslipidaemia, 14 (5.4%) and diabetes, 2 (0.8%).
T74 9550-9602 Sentence denotes A total of 15.7% (41) indicated tobacco consumption.
T75 9603-9773 Sentence denotes Of the 306 persons surveyed, 158 (51.6%) reported the appearance of a new headache during the period of study, of whom 65 (41.1%) had previously had a headache (migraine:
T76 9774-9794 Sentence denotes 27 (17.1%), tension:
T77 9795-9817 Sentence denotes 26 (16.5%) and others:
T78 9818-9829 Sentence denotes 11 (6.9%)).
T79 9830-9915 Sentence denotes There were 103 (33.7%) subjects who did not observe the appearance of a new headache.
T80 9916-10047 Sentence denotes A 14.7% were undecided on the answer ‘I don't know’ or the answer was ‘maybe’; these 45 subjects were eliminated from the analysis.
T81 10048-10214 Sentence denotes They were also asked about the presence of other symptoms such as sleep disturbance, loss of concentration, irritability, photophobia, sonophobia, nausea or vomiting.
T82 10215-10267 Sentence denotes Table 1 shows the characteristics of the population.
T83 10268-10376 Sentence denotes Table 1 Baseline conditions and mask and Personal Protective Equipment (PPE) usage among healthcare workers
T84 10377-10409 Sentence denotes Total De novo headache P value
T85 10410-10417 Sentence denotes No Yes
T86 10418-10442 Sentence denotes N= 261 (n=103) (n=158)
T87 10443-10504 Sentence denotes Age, years (SD) 42.9 (10.7) 40.8 (11.4) 44.4 (10.1) 0.009
T88 10505-10563 Sentence denotes Female gender 208 (79.7%) 73 (31.1%) 135 (64.9%) 0.004
T89 10564-10584 Sentence denotes Occupation 0.0001
T90 10585-10628 Sentence denotes  Doctor 112 (42.9%) 61(54.5%) 51 (45.5%)
T91 10629-10670 Sentence denotes  Nurse 95 (36.4%) 33 (34.7%) 62(65.3%)
T92 10671-10711 Sentence denotes  Others 54 (20.7%) 9(16.7%) 45(83.3%)
T93 10712-10733 Sentence denotes Work shift <0.0001
T94 10734-10798 Sentence denotes  Mornings and 24-hour duties 89 (34.1%) 51 (57.3%) 38 (42.7%)
T95 10799-10851 Sentence denotes  Rotating shifts 91 (34.9%) 26 (28.6%) 65 (71.4%)
T96 10852-10895 Sentence denotes  Others 81 (31.0%) 26 (32.1%) 55 (67.9%)
T97 10896-10922 Sentence denotes Type of face mask 0.029
T98 10923-10975 Sentence denotes  Surgical mask 208 (79.7%) 89 (42.8%) 119 (57.2%)
T99 10976-11021 Sentence denotes  N95/FFP2 53 (20.3%) 14 (26.4%) 39 (73.6%)
T100 11022-11095 Sentence denotes Number of hours worn per day (SD) 6.9 (2.3) 6.8 (2.4) 7.0 (2.2) 0.474
T101 11096-11115 Sentence denotes Use of another PPE:
T102 11119-11124 Sentence denotes 0.203
T103 11125-11173 Sentence denotes  Face shield 54 (20.7%) 21 (38.9%) 33 (61.1%)
T104 11174-11229 Sentence denotes  Protective eyewear 33 (12.6%) 13 (39.4%) 20 (60.6%)
T105 11230-11279 Sentence denotes  Complete PPE 46 (17.6%) 16 (34.8%) 30 (65.2%)
T106 11280-11338 Sentence denotes Confirmed COVID-19 12 (4.6%) 4 (33.3%) 8 (66.7%) 0.161
T107 11339-11404 Sentence denotes Pre-existing headache 110 (42.1%) 45 (40.9%) 65 (59.1%) 0.683
T108 11405-11416 Sentence denotes Comorbidity
T109 11417-11467 Sentence denotes  Allergy 34 (13.0%) 16 (47.1%) 18(52.9%) 0.331
T110 11468-11516 Sentence denotes  Asthma 17 (6.5%) 11 (64.7%) 6 (35.3%) 0.028
T111 11517-11567 Sentence denotes  Tobacco 41 (15.7%) 8 (19.5%) 33 (80.5%) 0.004
T112 11568-11630 Sentence denotes  Arterial hypertension 18 (6.9%) 9 (50.0%) 9 (50.0%) 0.789
T113 11631-11680 Sentence denotes  Cardiopathy 1 (0.4%) 0 (0.0%) 1 (100%) 0.419
T114 11681-11734 Sentence denotes  Dyslipidaemia 14 (5.4%) 7 (50.0%) 7 (50.0%) 0.76
T115 11735-11782 Sentence denotes  Diabetes 2 (0.8%) 1 (50.0%) 1 (50.0%) 0.76
T116 11783-11841 Sentence denotes  Thyroid disease 28 (10.7%) 9 (32.1%) 19 (67.9%) 0.402
T117 11842-11892 Sentence denotes  Anxiety 26 (10.0%) 6 (23.1%) 20 (76.9%) 0.072
T118 11893-11941 Sentence denotes  Others 16 (6.1%) 4 (25.0%) 12 (75.0%) 0.222
T119 11942-11956 Sentence denotes Other symptoms
T120 11957-12019 Sentence denotes  Sleep disturbance 79 (30.3%) 11 (13.9%) 68 (86.1%) 0.0001
T121 12020-12086 Sentence denotes  Loss of concentration 73 (28.0%) 14 (19.2%) 59 (80.8%) 0.0001
T122 12087-12143 Sentence denotes  Irritability 74 (28.4%) 18 (24.3%) 56 (75.7%) 0.002
T123 12144-12198 Sentence denotes  Photophobia 31 (11.9%) 8 (25.8%) 23 (74.2%) 0.097
T124 12199-12250 Sentence denotes  Sonophobia 24 (9.2%) 6 (25.0%) 18 75.0%) 0.128
T125 12251-12311 Sentence denotes  Sickness/vomiting 24 (9.2%) 11 (45.8%) 13 (54.2%) 0.503
T126 12312-12378 Sentence denotes FFP2, filtering face pieces; N95, 95% particle filtering capacity.
T127 12379-12491 Sentence denotes During April, the month prior to the survey, participants with ‘de novo’ headache presented a median of 12 (IQR:
T128 12492-12531 Sentence denotes 13) days of headache, median of 4 (IQR:
T129 12532-12661 Sentence denotes 3) days in the week prior to the survey, and the pain presented an average intensity on the Visual Analogue Scale (VAS) of 6 (SD:
T130 12662-12667 Sentence denotes 1.5).
T131 12668-12834 Sentence denotes In 74 (47.4%) subjects, the duration was from 1 to 4 hours; in 46 (29.5%), from 4 to 8 hours; in 21 (13.5%), from 8 to 12 hours; and in 15 (9.6%), more than 12 hours.
T132 12835-12931 Sentence denotes In subjects with previous headache, the duration of episodes was significantly higher (p=0.008).
T133 12932-13003 Sentence denotes The response to analgesics was good or very good in 61.4% of the cases.
T134 13004-13128 Sentence denotes Only two (1.3%) subjects had to consult the emergency department for headache, and no subject had been admitted to hospital.
T135 13129-13263 Sentence denotes With respect to the impact of headache in the work setting, lack of concentration on tasks was the main report (105 (66.5%) subjects).
T136 13264-13325 Sentence denotes Table 2 shows the main characteristics of ‘de novo’ headache.
T137 13326-13400 Sentence denotes Table 2 Characteristics of headache in healthcare worker (HCW) mask users
T138 13401-13506 Sentence denotes All HCW with de novo headache HCW without pre-existing headache HCW with pre-existing headache P value
T139 13507-13530 Sentence denotes (n=158) (n=93) (n=65)
T140 13531-13603 Sentence denotes Days with headache/month (SD) 13.2 (7.2) 13.0 (7.4) 13.5 (7.1) 0.746
T141 13604-13672 Sentence denotes Days with headache/week (SD) 3.8 (1.7) 3.8 (1.7) 3.9 (1.7) 0.827
T142 13673-13737 Sentence denotes Mean pain level, VAS (SD) 5.9 (1.5) 5.8 (1.5) 6.1 (1.4) 0.08
T143 13738-13768 Sentence denotes Duration time (hours) 0.008
T144 13769-13809 Sentence denotes  1–4 74 (47.4%) 52 (57.1%) 22 (33.8%)
T145 13810-13850 Sentence denotes  4–8 46 (29.5%) 23 (25.3%) 23 (35.4%)
T146 13851-13891 Sentence denotes  8–12 21 (13.5%) 12 (13.2%) 9 (13.8%)
T147 13892-13929 Sentence denotes  >12 15 (9.6%) 4 (4.4%) 11 (16.9%)
T148 13930-13957 Sentence denotes Analgesic response 0.342
T149 13958-14012 Sentence denotes  Good or very good 97 (61.4%) 61 (65.6%) 36 (55.4%)
T150 14013-14057 Sentence denotes  Regular 46 (29.1%) 23 (24.7%) 23 (35.4%)
T151 14058-14105 Sentence denotes  Bad or very bad 15 (9.5%) 9 (9.7%) 6 (9.2%)
T152 14106-14133 Sentence denotes Headache impact on HCW (SD)
T153 14134-14186 Sentence denotes  Occupational 4.0 (2.6) 3.5 (2.6) 4.6 (2.5) 0.02
T154 14187-14234 Sentence denotes  Family 4.4 (2.7) 4.1 (2.6) 4.9 (2.5) 0.084
T155 14235-14284 Sentence denotes  Personal 5.0 (2.6) 4.7 (2.7) 5.5 (2.4) 0.049
T156 14285-14332 Sentence denotes  Social 4.8 (2.8) 4.4 (2.8) 5.4 (2.7) 0.021
T157 14333-14383 Sentence denotes SD, Standar Deviation; VAS, Visual Analogue Scale.
T158 14384-14653 Sentence denotes Of the 65 subjects with a previous headache, 83.1% (54) indicated a modification in the characteristics of their habitual headaches, 81.0% (47) a change in location, 67.2% (39) in frequency, 36.2% (21) in intensity and 25.9% (15) in the response to habitual analgesics.
T159 14654-14891 Sentence denotes In the univariate analysis, the factors associated with the appearance of ‘de novo’ headache were age, female sex, type of profession, use of filter mask (KN95 or FFP2), work shift, being a tobacco user, suffering from anxiety or asthma.
T160 14892-15078 Sentence denotes In the multivariate analysis, the use of filter masks and the type of profession behaved as independent predictors of headache risk, while being asthmatic behaved as a protective factor.
T161 15079-15303 Sentence denotes The occurrence of headache is associated with the use of a filter mask (FFP2 or KN95), OR 2.14 (95% CI 1.07 to 4.32); being a health worker, OR 6.94 (95% CI 3.01 to 16.04) or a nurse, OR 2.09 (95% CI 1.18 to 3.72) (table 3).
T162 15304-15383 Sentence denotes Table 3 Univariate and multivariate analysis of factors of baseline conditions
T163 15384-15437 Sentence denotes Variables Univariate analysis Multivariate analysis
T164 15438-15478 Sentence denotes OR 95% CI P valúe OR 95% CI P valúe
T165 15479-15509 Sentence denotes Age 1.03 1.01 to 1.06 0.009
T166 15510-15550 Sentence denotes Female gender 2.41 1.31 to 4.45 0.005
T167 15551-15594 Sentence denotes Doctor Ref Ref 0.0001 Ref Ref <0.0001
T168 15595-15641 Sentence denotes Nurse 2.25 1.28 to 3.94 2.09 1.18 to 3.72
T169 15642-15693 Sentence denotes Other HCW 5.98 2.67 to 13.4 6.94 3.01 to 16.04
T170 15694-15775 Sentence denotes Filter mask versus surgical 2.08 1.07 to 4.07 0.026 2.14 1.07 to 4.32 0.027
T171 15776-15821 Sentence denotes Mornings and 24-hour duties Ref Ref 0.0001
T172 15822-15857 Sentence denotes Rotating shifts 3.35 1.81 to 6.23
T173 15858-15895 Sentence denotes Other work shifts 2.83 1.52 to 5.32
T174 15896-15955 Sentence denotes Asthma 0.33 0.12 to 0.92 0.03 0.29 0.09 to 0.89 0.026
T175 15956-15990 Sentence denotes Tobacco 3.13 1.39 to 7.01 0.003
T176 15991-16025 Sentence denotes Anxiety 2.34 0.91 to 6.05 0.063
T177 16026-16148 Sentence denotes 95%CI, 95% Confidence Interval; HCW, healthcare workers; HCW, healthcare worker; OR, odds ratio; Ref., Reference category.
T178 16149-16288 Sentence denotes According to the type of mask used, there was no difference in the number of days with headache in the month prior to the survey, 13.4 (SD:
T179 16289-16306 Sentence denotes 7.4) vs 12.6 (SD:
T180 16307-16347 Sentence denotes 6.9); nor in the previous week, 3.9 (SD:
T181 16348-16364 Sentence denotes 1.6) vs 3.6 (SD:
T182 16365-16418 Sentence denotes 1.7); but in the intensity according to VAS, 5.7 (SD:
T183 16419-16435 Sentence denotes 1.5) vs 6.5 (SD:
T184 16436-16450 Sentence denotes 1.2), p=0.004.
T185 16451-16742 Sentence denotes The impact of headache in subjects with a filter mask as opposed to surgical mask was worse in the four aspects evaluated by the Likert scale: occupational, 4.44 vs 3.81 (p=0.206); family, 5.10 vs 4.20 (p=0.065); personal, 5.64 vs 4.84 (p=0.05) and social, 5.46 vs 4.58 (p=0.076) (figure 1).
T186 16743-16848 Sentence denotes The impact was also greater in subjects with a previous headache in the four aspects evaluated (table 2).
T187 16849-16987 Sentence denotes Figure 1 Impact of headache in subjects with a filter mask as opposed to surgical mask in the four aspects evaluated by the Likert scale.
T188 16988-17090 Sentence denotes Likert scale rating: it indicates the degree of limitation due to headache in different areas of life.
T189 17091-17112 Sentence denotes 0: none; 10: maximum.
T190 17113-17411 Sentence denotes Regarding the evaluation of self-perceived work stress by means of the 12 items of the PPQ, individuals with ‘de novo’ headache versus those without headache have significantly worse scores in all aspects evaluated, except for the decrease in appetite where no significant differences are observed.
T191 17412-17522 Sentence denotes Figure 2 shows graphically the evaluation of occupational stress according to the presence of headache or not.
T192 17523-17724 Sentence denotes The use of a filter mask compared with surgical mask only implies a significantly worse score in two aspects: gastrointestinal discomfort (p=0.047) and greater sensation of extreme tiredness (p=0.004).
T193 17725-17845 Sentence denotes Figure 2 Evaluation of self-perceived work stress by means of the 12 items of the Psychosomatic Problems Questionnaire.
T194 17847-17857 Sentence denotes Discussion
T195 17858-17960 Sentence denotes The current COVID-19 pandemic has caused a substantial change in the workflow of health professionals.
T196 17961-18027 Sentence denotes One of the most important characteristics has been the use of PPE.
T197 18028-18127 Sentence denotes Masks are a critical preventive measure and are most essential when social distancing is difficult.
T198 18128-18379 Sentence denotes It is clear that adherence to universal mask policies reduces the transmission of SARS-CoV-2.14 But, according to the data obtained, we demonstrate a statistically significant association between the use of filter masks and the appearance of headache.
T199 18380-18500 Sentence denotes In the physiopathology of a new-onset headache, the exact mechanisms may be multiple, complex and not always well known.
T200 18501-18850 Sentence denotes Peripheral nociceptive structures and central sensitisation mechanisms may be involved in their development.15 16 The current International Headache Classification proposes, generically for secondary headaches, that the diagnostic criteria do not require remission or improvement of the underlying causal disorder before the diagnosis is formalised.
T201 18851-19150 Sentence denotes For acute processes, a close temporal relationship between the onset of the headache and the onset of the suspected causal disorder is usually sufficient.11 Following this classification, mask-associated headache would probably be a multifactorial disorder with unknown aetiopathogenesis at present.
T202 19151-19359 Sentence denotes Hypothetically, a number of factors may explain the association with filter mask use, including hypoxia, hypercapnia, local compression and mechanical phenomena, as well as anxiety about wearing the device.10
T203 19360-20576 Sentence denotes In the scientific literature there are not many studies that relate the use of face masks to changes in the concentration of oxygen and/or carbon dioxide (CO2), but it seems a plausible hypothesis due to the barrier element that is interposed in the physiological ventilation mechanism.17 In a Taiwanese cohort of 39 patients with end-stage renal disease who wore N95 masks during the 2002 SARS outbreak, the study found a significant reduction in arterial oxygen pressure from baseline and an increase in other respiratory adverse effects.18 Another study conducted in a cohort of 130 astronauts subjected to high CO2 pressures during controlled training showed a significantly higher incidence of headache in the exposed group, in addition to respiratory symptoms and difficulty in concentrating.19 At the University of Wollongong, a study on the effects of CO2 inhalation on workers wearing respiratory protection devices showed that high levels of CO2 were associated with feelings of discomfort and significantly reduced tolerance and time of device use.20 The effect on respiratory physiology and muscle performance of wearing training masks designed to simulate a variable altitude situation has been studied.
T204 20577-20993 Sentence denotes The results are mixed in terms of objective performance parameters, however, it seems that mask use reduces working speed and negatively influences levels of alertness and task focus.21 In 2014, a pilot study evaluated the consequences on respiratory physiology of surgical mask and N95 face mask use and the extent to which nasal inspiratory and expiratory resistance and discomfort were altered in the individuals.
T205 20994-21327 Sentence denotes Physiological changes such as increased respiratory resistances were observed after 3 hours of use.22 Headache associated with filter mask use could be included according to ICHD-311 in the section on headaches due to homeostatic disorders where those related to alteration of oxygen and CO2 partial pressure parameters are included.
T206 21328-21657 Sentence denotes Another phenomenon probably related to the physiopathology of headache after PPE use is the external compression that it generates, as recently reflected by the group of Ong et al.23 In most cases there is a temporal relationship between the use of devices and the headache, as well as the topographical location of the headache.
T207 21658-22046 Sentence denotes As with homeostatic changes, ICHD-3 typifies a type of headache attributable to uninterrupted compression or traction of pericranial soft tissues.11 Pressure or tractional forces from the mask, together with the accompanying straps, may lead to local tissue damage and exert an irritative effect on the underlying superficial sensory nerves innervating the face, head and cervical region.
T208 22047-22142 Sentence denotes There are several examples in the literature that would be consistent with this mechanism.10–24
T209 22143-22209 Sentence denotes The last factor to be mentioned is the level of anxiety or stress.
T210 22210-22467 Sentence denotes Multiple ways of relating stress and headache have been described, either as ‘de novo’ or as exacerbation in an individual with primary headache.25 In the case of the SARS-CoV-2 pandemic, healthcare workers may be affected by critical incident stress (CIS).
T211 22468-22635 Sentence denotes Critical incidents are events in which people witness or experience tragedy, death, serious injury or threatening situations, which can have a strong emotional impact.
T212 22636-22853 Sentence denotes The signs and symptoms of CIS can be physical, cognitive, emotional and behavioural.26 In our work, we observed that the level of stress in subjects with headache is significantly worse in all aspects measured by PPQ.
T213 22854-22982 Sentence denotes We also showed that the risk of developing headache is higher among nurses and other health professionals than among physicians.
T214 22983-23068 Sentence denotes The explanation for this result is complex, but there are three plausible hypotheses.
T215 23069-23472 Sentence denotes As a general rule, doctors live with a higher level of stress in the course of their work, and therefore, situations considered conflicting do not increase their usual stress threshold excessively.27 It could also be explained by the use of negative coping strategies in some professional groups as opposed to others28; these strategies, not measured in our work, would be related to professional level.
T216 23473-23856 Sentence denotes The third potential explanation, in line with some published studies, is that the higher risk of headache among nurses and other health professionals than in the medical group, is due to the differential characteristics of the workers' occupation, which would involve the use of other devices, cleaning materials, activities with greater energy expenditure or changing work shifts.29
T217 23857-24046 Sentence denotes Different factors or comorbidities that may influence the development of headache have been described in the literature.30 If we look at risk markers, age and sex deserve special attention.
T218 24047-24871 Sentence denotes The female sex is closely related to the development of ‘de novo’ headache.31 Age is a determining factor in the classification of headache according to the International Headache Society.11 Several studies have shown that pain intensity,32 the degree of headache disability and the possibility of secondary headache occurrence are age-related factors.33 In terms of other individually modifiable risk factors, the relationship between blood pressure changes and primary headache should be highlighted, as they share mechanisms of action such as vascular endothelial dysfunction or poor cardiovascular autonomic regulation.34 However, in our study we did not find a clear association between different comorbidities of the individual and the appearance of headache, except for tobacco consumption in the univariate analysis.
T219 24872-24985 Sentence denotes In a review of the relationship between smoking and the occurrence of headache, controversial data were obtained.
T220 24986-25130 Sentence denotes The studies are mostly retrospective and limited, and there is no definite evidence that tobacco is an independent cause of headache occurrence.
T221 25131-25331 Sentence denotes However, most patients with migraine define it as a trigger.35 Headache is one of the most pronounced symptoms in patients suffering from asthma, a fact that has been described in a few papers so far.
T222 25332-25518 Sentence denotes In a study of 93 patients, a statistically significant difference was found in this area, as 62.4% of asthmatics had headache, whereas in the control group the percentage was only 32.8%.
T223 25519-25950 Sentence denotes Other factors such as the use of steroid inhalers, the presence of rhinitis, conjunctivitis or respiratory parameters, such as forced expiratory volume in one second, were studied and characterised.36 In our study, being asthmatic would act as a protective factor against headache associated with mask use, perhaps because of a greater tolerance to hypoxia, and therefore a higher threshold for developing headache for this reason.
T224 25951-26052 Sentence denotes It is especially important to discuss possible methods to reduce the impact of PPE-induced headaches.
T225 26053-26515 Sentence denotes Our findings are in agreement with multiple studies showing that headache triggers are often associated with a change in homeostasis, underscoring the importance of addressing these factors to optimise headache control.37 For example, encouraging the use of powered air-purifying respirators (PAPRs) is a method for healthcare workers working in high-risk areas and for long periods, since the PAPR provides additional safety and reduces the accumulation of CO2.
T226 26516-26730 Sentence denotes On the other hand, we recognise that the conventional N95 face mask fit considers only the overall fit factor and does not take into account the level of tolerability, especially when worn for long periods of time.
T227 26731-27122 Sentence denotes Since current mask designs can cause headaches and affect compliance, the administrators should think about devising new work schedules for healthcare workers (like shorter working hours) and for people who need to wear a filter mask.38 Through novel engineering solutions, next-generation face masks need to be better designed with priority on tolerability and less predisposed to headache.
T228 27124-27135 Sentence denotes Limitations
T229 27136-27274 Sentence denotes Our study has some limitations that should be noted: the sample is one of convenience and there has been no previous probability sampling.
T230 27275-27340 Sentence denotes We could not include or under-represent some professional groups.
T231 27341-27441 Sentence denotes The study is cross-sectional, which helps us to formulate hypotheses, but we cannot prove causality.
T232 27442-27701 Sentence denotes We have not taken into account the temporal evolution of the headache in the health professionals who present it, nor have we taken into account other external factors that may influence the headache, such as the exact conditions of the site and type of work.
T233 27702-27971 Sentence denotes The last limitation is that we have not considered other confounding variables that could potentially condition a headache, such as dehydration due to the continued use of full PPE in a hot environment or lifestyle, or diet changes derived from stress or lack of sleep.
T234 27973-27983 Sentence denotes Conclusion
T235 27984-28166 Sentence denotes In our study, we described the occurrence of ‘de novo’ headache with the use of filter masks and their negative impact on multiple dimensions of the life of healthcare professionals.
T236 28167-28319 Sentence denotes We propose headache associated with the use of this type of mask as a new subtype of headache, of a multifactorial nature and complex aetiopathogenesis.
T237 28320-28583 Sentence denotes Since the use of these devices will tend to become more widespread due to the implications of the pandemic, we believe it is important to promote prevention and protection strategies that guarantee the safety of workers, without undermining their quality of life.