Des agents virtuels sur smartphone pour faire face aux plaintes de sommeil pendant le confinement du COVID-19 : étude de faisabilité

Objectif Étudier la faisabilité de KANOPEE, une application qui dispense un entretien avec un agent virtuel, dans le but de dépister et de prendre en charge les plaintes de sommeil, pendant le confinement du COVID-19. Méthodes 2069 utilisateurs ont téléchargé KANOPEE entre le 22 avril et le 5 mai 2020. Si, à la suite du dépistage basé sur l'Index de Sévérité de l'Insomnie (ISI), les sujets présentent des plaintes de sommeil significatives (ISI > 14), un programme interventionnel en 2 étapes est proposé : – compléter un agenda du sommeil sur le smartphone pendant une semaine ;– suivre des recommandations de sommeil personnalisées pendant 10 jours. Les mesures incluent l'ISI, les horaires de sommeil nocturne (via l'agenda), et l'acceptabilité de l'agent virtuel. Résultats Parmi les 773 sujets qui présentaient des plaintes de sommeil, 34 % ont complété l'étape 1 de l'intervention. Pour ces derniers, une amélioration significative des plaintes de sommeil (ISIdépistage : 18,56 ;ISIfin étape 1 : 15,99 ;p < .001) et de leur sommeil nocturne est observée. Chez les 47 sujets qui ont suivi l'étape 2, une amélioration de l'ISI est aussi observée par rapport à la mesure initiale (ISIdépistage : 18,87 ;ISIfin étape 2 : 14,68 ;p < .001). L'agent virtuel est bien accepté par les utilisateurs (61,7 % de « très satisfaits »). Conclusion Ces résultats préliminaires montrent que KANOPEE est une solution prometteuse pour dépister les plaintes de sommeil en population générale et propose des interventions pratiques et efficaces pour les sujets rapportant des plaintes de sommeil.

Emotional Exhaustion, a Proxy for Burnout, Is Associated with Sleep Health in French Healthcare Workers without Anxiety or Depressive Symptoms: A Cross-Sectional Study.

Burnout is frequent among healthcare workers, and sleep problems are suspected risk factors. The sleep health framework provides a new approach to the promotion of sleep as a health benefit. The aim of this study was to assess good sleep health in a large sample of healthcare workers and to investigate its relationship with the absence of burnout among healthcare workers while considering anxiety and depressive symptoms. A cross-sectional Internet-based survey of French healthcare workers was conducted in summer 2020, at the end of the first COVID-19 lockdown in France (March to May 2020). Sleep health was assessed using the RU-SATED v2.0 scale (RegUlarity, Satisfaction, Alertness, Timing, Efficiency, Duration). Emotional exhaustion was used as a proxy for overall burnout. Of 1069 participating French healthcare workers, 474 (44.3%) reported good sleep health (RU-SATED > 8) and 143 (13.4%) reported emotional exhaustion. Males and nurses had a lower likelihood of emotional exhaustion than females and physicians, respectively. Good sleep health was associated with a 2.5-fold lower likelihood of emotional exhaustion and associations persisted among healthcare workers without significant anxiety and depressive symptoms. Longitudinal studies are needed to explore the preventive role of sleep health promotion in terms of the reduction in burnout risk.

Efficacy of a Smartphone-Based Virtual Companion to Treat Insomniac Complaints in the General Population: Sleep Diary Monitoring Versus an Internet Autonomous Intervention.

(1) Background: Insomnia is the most prevalent sleep disorder worldwide and cognitive behavioral therapy is the front-line treatment. Digital health technologies have a role to play in screening and delivering interventions remotely and without the need for human intervention. The KANOPEE app, which provides a screening and behavioral intervention for insomnia symptoms through an interaction with a virtual agent, showed encouraging results in previous studies during and after the COVID-19 lockdown, but has not yet been evaluated in a controlled study. This study aims at comparing the benefits of KANOPEE, a smartphone application dealing with insomnia complaints, with another application proposing an electronic sleep diary named "My Sleep Diary". The acceptance and potential benefits of these digital solutions are tested in real-life settings (i.e., without soliciting human medical resources) and in the general population. (2) Methods: Subjects were included if they downloaded one of the apps between December 2020 and October 2021, and were of legal age. Both apps were available on downloading platforms in France. Primary outcome was Insomnia Severity Index (ISI), and secondary outcomes were total sleep time (TST), sleep efficiency (SE) and wake time after sleep onset (WASO). (3) Results: A total of 535 users completed the intervention with KANOPEE and 489 users completed My Sleep Diary, both for 17 days. KANOPEE users improved their ISI score significantly more than sleep diary users (interaction Time*Group: F(2,2002) = 17.3, p < 0.001). Similar results were found for nocturnal sleep parameters (TST) (KANOPEE users gained 48 min of sleep after intervention, while My Sleep Diary users gained only 16 min of sleep), and particularly in the population with moderate to severe initial sleep complaints (F(4,1980) = 8.9, p < 0.001). Other sleep markers (SE and WASO) were significantly improved in the KANOPEE users compared to the sleep diary ones (p < 0.001). (4) Conclusions: KANOPEE provides significantly greater benefits than an electronic sleep diary regarding reduction of insomnia complaints and estimated nocturnal sleep characteristics in a self-selected sample of the general population. Population with the most severe initial ISI score (≥15) benefited the most from the KANOPEE App compared to filling up a simple sleep diary.

Circadian misalignment is associated with Covid-19 infection.

BACKGROUND: Circadian system contributes to the regulation of inflammatory processes, but the role of circadian misalignment as a risk factor for contracting Covid-19 has up to now been poorly studied. The aim of this study was to explore the relationship between circadian misalignment (chronic disturbance of the circadian system) and the risk of Covid-19 infection in a population of subjects suspected of contact or infection with SARS-CoV-2. METHODS: Cross-sectional single-center study conducted during a period without lockdown in winter 2021. Recruitment took place in a Covid-19 outpatient testing center. Subjects between 18 and 45 years old were included whether they were symptomatic or not, healthcare workers or not, in contact with a Covid-19 case or not. To determine social jetlag, a proxy of circadian misalignment, they were asked about their usual sleep-wake behaviors. Usual sleep duration and sleep-wake timing were explored on workdays and free days. Social jetlag was defined as at least 2 h shift of circadian alignment (defined as the difference between mid-sleep on workdays and mid-sleep on free days, mid-sleep as the median between bedtime and rise time). RESULTS: One thousand fourteen subjects were included (sampling rate: 10.8%, 39% men, mean age 28 ± 8) with 56 subjects positive for Covid-19 (positivity rate: 5.5%). Usual mean sleep duration was equivalent in both groups (7h47 versus 7h49, p = 0.733). Social jetlag greater than 2 h comprised 33.3% of subjects in the Covid-19 group versus 20.6% in the control group (p = 0.026). After adjustment on age, gender, BMI and work schedules, subjects presenting with social jetlag greater than 2 h had a 2.07-fold higher likelihood to test positive than subjects who had identical sleep-wake timing on workdays and free days (OR = 2.07, 95%CI = [1.12-3.80], p = 0.024). CONCLUSION: Circadian misalignment not only is present in subjects infected by Covid-19 but could also be responsible for a higher likelihood of being infected. The chronobiological impact on the immune system or a higher likelihood of being exposed to social contacts during nocturnal activities could explain our findings, which need to be confirmed in a future large cohort study. Regular sleep-wake timing could ultimately become a target for preventing Covid-19 infection.

Prevalent, incident, and persistent insomnia in a population-based cohort tested before (2018) and during the first-wave of COVID-19 pandemic (2020).

STUDY OBJECTIVES: High rates of sleep and mental health problems have been reported during the COVID-19 pandemic, but most of the evidence is retrospective without pre-pandemic data. This study documented rates of prevalent, incident, and persistent insomnia and psychological symptoms during the COVID-19 pandemic (2020) compared to pre-pandemic data (2018). METHODS: Data were derived from a longitudinal, population-based study of insomnia in Canada. When the first lockdown started in the province of Quebec, a subsample of participants who had completed the latest 2018 follow-up were surveyed (April to May 2020) about their sleep, insomnia, and psychological symptoms since the beginning of the pandemic. Prevalence, incidence, and persistence rates of insomnia, and severity of stress, anxiety, and depressive symptoms were estimated, as well as their associations with confinement, loneliness, social support, use of electronics, and other lifestyle changes occurring during the pandemic. A sleep/health survey and validated questionnaires of insomnia, sleep quality, stress, fatigue, anxiety, and depression were administered at both assessments. RESULTS: The sample consisted of 594 adults (mean age: 48.3 ± 13.1 years; 64.0% women). Prevalence of insomnia increased from 25.4% to 32.2% (symptoms) and from 16.8% to 19% (syndrome) from 2018 to 2020, for an overall 26.7% increase in insomnia rates. Of those classified as good sleepers in 2018 (n = 343), 32.6% (n = 112) had developed new insomnia during the COVID-19 pandemic. Among participants who had insomnia in 2018, the persistence rate was 76.5% 2 years later. There was a significant worsening of sleep quality, fatigue, anxiety, and depression (all ps < .005) during the COVID-19 pandemic compared to 2018. Significant associations were found between sleep and psychological symptoms and with living alone and being in confinement, lower social support, increased time using electronic devices, reduced physical exercise, and higher financial stress. CONCLUSIONS: The COVID-19 pandemic is associated with significant increases in insomnia and psychological symptoms compared to the pre-pandemic period. Large scale public sleep and mental health intervention programs should be prioritized during and after a pandemic such as the COVID-19.

Brain reactivity to humorous films is affected by insomnia.

STUDY OBJECTIVES: Emotional reactivity to negative stimuli has been investigated in insomnia, but little is known about emotional reactivity to positive stimuli and its neural representation. METHODS: We used 3 Tesla functional magnetic resonance imaging (fMRI) to determine neural reactivity during the presentation of standardized short, 10- to 40-seconds, humorous films in patients with insomnia (n = 20, 18 females, aged 27.7 +/- 8.6 years) and age-matched individuals without insomnia (n = 20, 19 females, aged 26.7 +/- 7.0 years) and assessed humor ratings through a visual analog scale. Seed-based functional connectivity was analyzed for the left and right amygdalas (lAMYG and rAMYG, respectively) networks: group-level mixed-effects analysis (FLAME; FMRIB Software Library [FSL]) was used to compare amygdala connectivity maps between groups. RESULTS: fMRI seed-based analysis of the amygdala revealed stronger neural reactivity in patients with insomnia than in controls in several brain network clusters within the reward brain network, without humor rating differences between groups (p = 0.6). For lAMYG connectivity, cluster maxima were in the left caudate (Z = 3.88), left putamen (Z = 3.79), and left anterior cingulate gyrus (Z = 4.11), whereas for rAMYG connectivity, cluster maxima were in the left caudate (Z = 4.05), right insula (Z = 3.83), and left anterior cingulate gyrus (Z = 4.29). Cluster maxima of the rAMYG network were correlated with hyperarousal scores in patients with insomnia only. CONCLUSIONS: The presentation of humorous films leads to increased brain activity in the neural reward network for patients with insomnia compared with controls, related to hyperarousal features in patients with insomnia, in the absence of humor rating group differences. These novel findings may benefit insomnia treatment interventions. CLINICAL TRIAL: The Sleepless Brain: Neuroimaging Support for a Differential Diagnosis of Insomnia (SOMNET). ClinicalTrials.gov identifier: NCT02821234; https://clinicaltrials.gov/ct2/show/NCT02821234.

Smartphone-based virtual agents and insomnia management: A proof-of-concept study for new methods of autonomous screening and management of insomnia symptoms in the general population.

Insomnia is the most frequent sleep disorder, and the COVID-19 crisis has massively increased its prevalence in the population, due to psychosocial stress or direct viral contamination. KANOPEE_2 is a smartphone-based application that provides interactions with a virtual agent to autonomously screen and alleviate insomnia symptoms through an intervention programme giving personalized advices regarding sleep hygiene, relaxation techniques and stimulus-control. In this proof-of-concept study, we tested the effects of KANOPEE_2 among users from all over the country (France) who downloaded the app between 1 June and 26 October 2020 (to focus on effects after the end of COVID-19 confinement). Outcome measures include insomnia severity (Insomnia Severity Index) and sleep/wake schedules measured by a sleep diary. One-thousand and thirty-four users answered the screening interview (Mage  = 43.76 years; SD = 13.14), and 108 completed the two-step programme (Mage  = 46.64 years; SD = 13.63). Of those who answered the screening, 42.8% did not report sleep complaints, while 57.2% presented mild-to-severe insomnia symptoms. At the end of the intervention, users reported significantly fewer sleep complaints compared with the beginning of the intervention (Insomnia Severity Indexbeginning  = 13.58; Insomnia Severity Indexend  = 11.30; p < 0.001), and significantly increased their sleep efficiency (sleep efficiencybeginning  = 76.46%; sleep efficiencyend  = 80.17%; p = 0.013). KANOPEE_2 is a promising solution both to provide autonomous evaluation of individuals' sleep hygiene and reduce insomnia symptoms over a brief and simple intervention. These results are very encouraging for addressing the issue of insomnia management in people exposed to major psychosocial stress and the consequences of COVID-19 infection.

Effectiveness and Acceptance of a Smartphone-Based Virtual Agent Screening for Alcohol and Tobacco Problems and Associated Risk Factors During COVID-19 Pandemic in the General Population.

Background: During the current COVID-19 pandemic, alcohol, and tobacco are the most available substances for managing stress and can induce a risk of addiction. KANOPEE is a smartphone application available to the general population using an embodied conversational agent (ECA) to screen for experiences of problems with alcohol/tobacco use and to provide follow-up tools for brief intervention. Objectives: This study aimed to determine if the smartphone KANOPEE application could identify people at risk for alcohol and/or tobacco use disorders in the context of the current COVID-19 pandemic, to assess adherence to a 7-day follow-up use diary, and to evaluate trust and acceptance of the application. Methods: The conversational agent, named Jeanne, interviewed participants about perceived problems with the use of alcohol and tobacco since the pandemic and explored risk for tobacco and alcohol use disorder with the five-item Cigarette Dependence Scale (CDS-5) and "Cut Down, Annoyed, Guilty, Eye-opener" (CAGE) questionnaire and experience of craving for each substance. Descriptive, univariate, and multivariate analyses were performed to specify personalized associations with reporting a problem with alcohol/tobacco use; descriptive analysis reported the experience with the intervention and acceptance and trust in the application. Results: From April 22 to October 26, 2020, 1,588 French participants completed the KANOPEE interview, and 318 answered the acceptance and trust scales. Forty-two percent of tobacco users and 27% of alcohol users reported problem use since the pandemic. Positive screening with CDS-5 and CAGE and craving were associated with reported problem use (p < 0.0001). Lockdown period influenced alcohol (p < 0.0005) but not tobacco use (p > 0.05). Eighty-eight percent of users reported that KANOPEE was easy to use, and 82% found Jeanne to be trustworthy and credible. Conclusion: KANOPEE was able to screen for risk factors for substance use disorder (SUD) and was acceptable to users. Reporting craving and being at risk for SUD seem to be early markers to be identified. Alcohol problem use seems to be more reliant on contextual conditions such as confinement. This method is able to offer acceptable, brief, and early intervention with minimal delay for vulnerable people.

Des agents virtuels sur smartphone pour faire face aux plaintes de sommeil pendant le confinement du COVID-19 : étude de faisabilité

Objectif Étudier la faisabilité de KANOPEE, une application qui dispense un entretien avec un agent virtuel, dans le but de dépister et de prendre en charge les plaintes de sommeil, pendant le confinement du COVID-19. Méthodes 2069 utilisateurs ont téléchargé KANOPEE entre le 22 avril et le 5 mai 2020. Si, à la suite du dépistage basé sur l’Index de Sévérité de l’Insomnie (ISI), les sujets présentent des plaintes de sommeil significatives (ISI>14), un programme interventionnel en 2 étapes est proposé : – compléter un agenda du sommeil sur le smartphone pendant une semaine ;– suivre des recommandations de sommeil personnalisées pendant 10jours. Les mesures incluent l’ISI, les horaires de sommeil nocturne (via l’agenda), et l’acceptabilité de l’agent virtuel. Résultats Parmi les 773 sujets qui présentaient des plaintes de sommeil, 34 % ont complété l’étape 1 de l’intervention. Pour ces derniers, une amélioration significative des plaintes de sommeil (ISIdépistage : 18,56 ;ISIfin étape 1 : 15,99 ;p<.001) et de leur sommeil nocturne est observée. Chez les 47 sujets qui ont suivi l’étape 2, une amélioration de l’ISI est aussi observée par rapport à la mesure initiale (ISIdépistage : 18,87 ;ISIfin étape 2 : 14,68 ;p<.001). L’agent virtuel est bien accepté par les utilisateurs (61,7 % de « très satisfaits »). Conclusion Ces résultats préliminaires montrent que KANOPEE est une solution prometteuse pour dépister les plaintes de sommeil en population générale et propose des interventions pratiques et efficaces pour les sujets rapportant des plaintes de sommeil.

Efficacité d’une TCC contre l’insomnie dispensée par un agent virtuel : Résultats pendant et après le confinement du COVID-19

Objectif Évaluer l’efficacité de KANOPEE, une application sur smartphone qui propose une interaction avec un agent virtuel dans le but de réaliser un dépistage et de délivrer une TCC-I personnalisée, et ce dans deux contextes particuliers : pendant le confinement du COVID-19, et durant les 4 mois qui ont suivi le confinement. Méthodes L’application est accessible gratuitement sur les plateformes de téléchargement. L’efficacité de KANOPEE était évaluée concernant : – la réduction des plaintes d’insomnie (mesurée à l’aide de l’Index de Sévérité de l’Insomnie [ISI]) ;– l’amélioration de l’efficacité de sommeil ([SE], mesurée par un agenda du sommeil). Résultats Pendant le confinement, 1 576 utilisateurs ont répondu à l’entretien de dépistage, et 47 ont complété le programme de TCC-I, et après le confinement,1662 ont répondu au dépistage et 83 sujets ont suivi la TCC-I. Les analyses multivariées révèlent que dans ces deux contextes les sujets ont significativement réduit leurs plaintes de sommeil (pendant le confinement : ISIbaseline=18,93 ;ISIfin de TCC-I=14,78 ;p<.001 ;après le confinement : ISIbaseline=17,00 ;ISIfin de TCC-I=12,18 ;p<.001) et augmenté leur efficacité de sommeil (pendant le confinement : ESbaseline=63,01 % ;ESfin de TCC-I=73,08 % ;p=.002 ;après le confinement : ESbaseline=68,86 % ;ESfin de TCC-I=79,91 % ;p=.001). Conclusion Les agents virtuels sont une solution prometteuse pour la mise en place de TCC-I auprès de la population générale, à la fois dans un contexte de crise sanitaire ou dans un contexte de soin généralisé.

Smartphone-Based Virtual Agents to Help Individuals With Sleep Concerns During COVID-19 Confinement: Feasibility Study.

BACKGROUND: The COVID-19 crisis and consequent confinement restrictions have caused significant psychosocial stress and reports of sleep complaints, which require early management, have increased during recent months. To help individuals concerned about their sleep, we developed a smartphone-based app called KANOPEE that allows users to interact with a virtual agent dedicated to autonomous screening and delivering digital behavioral interventions. OBJECTIVE: Our objective was to assess the feasibility of this app, in terms of inclusion rate, follow-up rate, perceived trust and acceptance of the virtual agent, and effects of the intervention program, in the context of COVID-19 confinement in France. METHODS: The virtual agent is an artificial intelligence program using decision tree architecture and interacting through natural body motion and natural voice. A total of 2069 users aged 18 years and above downloaded the free app during the study period (April 22 to May 5, 2020). These users first completed a screening interview based on the Insomnia Severity Index (ISI) conducted by the virtual agent. If the users were positive for insomnia complaints (ISI score >14), they were eligible to join the 2-stage intervention program: (1) complete an electronic sleep diary for 1 week and (2) follow personalized sleep recommendations for 10 days. We collected and analyzed the following measures: sociodemographic information, ISI scores and sleep/wake schedules, and acceptance and trust of the agent. RESULTS: Approximately 76% (1574/2069) of the app users completed the screening interview with the virtual agent. The virtual agent was well accepted by 27.4% (431/1574) of the users who answered the acceptance and trust questionnaires on its usability, satisfaction, benevolence, and credibility. Of the 773 screened users who reported sleep complaints (ISI score >14), 166 (21.5%) followed Step 1 of the intervention, and only 47 of those (28.3%) followed Step 2. Users who completed Step 1 found that their insomnia complaints (baseline mean ISI score 18.56, mean ISI score after Step 1 15.99; P<.001) and nocturnal sleep quality improved significantly after 1 week. Users who completed Step 2 also showed an improvement compared to the initial measures (baseline mean ISI score 18.87, mean ISI score after Step 2 14.68; P<.001). Users that were most severely affected (ISI score >21) did not respond to either intervention. CONCLUSIONS: These preliminary results suggest that the KANOPEE app is a promising solution to screen populations for sleep complaints and that it provides acceptable and practical behavioral advice for individuals reporting moderately severe insomnia.

Propositions Pour La Prise En Charge Des Troubles Du Sommeil Et De La Vigilance En Periode Epidemique Covid-19

RESUME Depuis mi-mars 2020, l’épidémie de COVID-19 a conduit à la suspension de la prise en charge des patients présentant des troubles du sommeil et de la vigilance. Bien qu’ayant rarement un caractère urgent, cette prise en charge ne peut être repoussée indéfiniment. Des propositions visant à établir les modalités de reprise progressive des activités de médecine du sommeil ont été élaborées grâce à la méthodologie CORE qui permet de dégager rapidement un consensus d’experts lorsque les données probantes sont insuffisantes. La réalisation d’explorations diagnostiques du sommeil et de la vigilance, doit être limitée aux patients pour lesquels la balance bénéfice-risque est favorable de manière indiscutable et lorsque les résultats sont susceptibles d’avoir un impact décisif sur une stratégie thérapeutique, en privilégiant la téléconsultation et les enregistrements ambulatoires. Le strict respect de la distanciation physique et des autres mesures barrière, le port d’équipement de protection par le personnel en fonction des tâches, l’utilisation de matériel à usage unique si possible, et des procédures rigoureuses de nettoyage et de désinfection de l’équipement et des locaux doit permettre de limiter les risques de transmission du SARS-CoV-2 entre le patient et les soignants. Les propositions du groupe d’experts sont valables au moment de leur publication mais seront bien entendu réévaluées et complétées très régulièrement en fonction de l’évolution des connaissances scientifiques et des recommandations des autorités de santé basées sur l’évolution de l’épidémie. SUMMARY Since mid-March 2020, the COVID-19 epidemic has led to the suspension of sleep clinic and sleep center operations. Although rarely urgent, sleep disorder management cannot be postponed indefinitely. Proposals to clarify the modalities for the gradual resumption of sleep medicine services have been developed using the CORE methodology, which allows for rapid expert consensus when the evidence-based data is weak. The performance of diagnostic sleep and alertness tests must be limited to patients for whom the benefit-risk balance is indisputably favorable and when the results are likely to have a decisive impact on a therapeutic strategy, with priority being given to teleconsultation and ambulatory recordings. Strict adherence to physical separation and other barrier measures, the use of protective equipment by staff and of single-use equipment whenever possible, and strict cleaning and disinfection procedures for equipment and premises should limit the risk of SARS-CoV-2 transmission between patient and staff members. The proposals of the expert group are valid at the time of their publication but will be re-evaluated and updated regularly according to the development of scientific knowledge and the recommendations of the health authorities based on the evolution of the epidemic.

Stratégies de gestion de l’impact du confinement sur le sommeil : Une synthèse d’experts

Résumé En plus de l’impact psychologique du confinement et de l’épidémie, il existe des répercussions sur le sommeil qu’il faut prendre en compte par la mise en place de stratégies adaptées afin de maintenir un bon état de santé mental et de santé général. Le confinement peut désorganiser le sommeil en impactant d’une part les rythmes circadiens par une diminution de l’intensité des synchroniseurs extérieurs, d’autre part peut favoriser l’insomnie dans cette période de stress aigu et enfin être source d’une privation de sommeil chez ceux qui sont en première ligne et qui gèrent la crise. Pour cela il est important de mettre en place certaines stratégies de préventions de ces perturbations de sommeil afin d’atténuer l’impact psychologique, infectieux et faire face de manière optimale à cette situation que nous vivons tous. In addition to the psychological impact of quarantine, there are sleep disturbances that must be taken into account by implementing appropriate strategies in order to maintain good mental and general health. Quarantine can disrupt sleep first in impacting circadian rhythms by decreasing the intensity of zeitgebers, second can promote insomnia in this period of acute stress and third can be a source of sleep deprivation in those on the front line and managing the crisis. For this it is important to put in place strategies to prevent these sleep disturbances in order to reduce the psychological, infectious impact and deal optimally with this situation that we are all experiencing.