Hypertrophic Cardiomyopathy
The final item of business today is a members' business debate on motion S1M-2243, in the name of Johann Lamont, on hypertrophic cardiomyopathy.
Motion debated,
That the Parliament notes the prevalence of the mainly inherited heart disease hypertrophic cardiomyopathy (HCM) which affects one in 500 of the population and is the number one cause of sudden death among under 25-year-olds; congratulates the Cardiomyopathy Association on its role in highlighting the condition and acknowledges the work of those involved in the association who have often suffered the loss of a family member because of HCM; further notes the Cardiomyopathy Association's campaign to secure screening by electrocardiogram and echo ultrasound of all first degree relatives of those who die as a result of this condition, and believes that the Scottish Executive, in partnership with the Health and Community Care Committee, the National Health Service and relevant groups working in this field, should consider how best those suffering from this condition might be identified and given access to the appropriate treatment.
I am proud and privileged to speak during members' business to the motion in my name on hypertrophic cardiomyopathy. I am grateful for all the support that the motion has attracted, which indicates the concern felt across the chamber about the issues that it highlights.
All members will acknowledge that we live in times of hubbub and change in the Parliament. I believe that the time for debating members' business is of real importance and plays a part in establishing the Scottish Parliament's worth. The debate represents business as usual, in particular for back benchers such as me. This is an important opportunity for the citizens of Scotland to see the structures and work of the Parliament being influenced by their priorities.
I must start with a confession. The subject of the debate is not an area in which I have great expertise—indeed, I am conscious of my total ignorance of the condition when I first heard about it. Since then I have been interested to see the often puzzled and bemused reactions of others when I have talked to them about hypertrophic cardiomyopathy. It is not easy to say it, never mind to understand it.
Hypertrophic cardiomyopathy is a mainly inherited disease that affects one in 500 of the population. It is the No 1 cause of sudden heart-related death among under-25s. It is a familial disease and each child of an affected person is exposed to a 50:50 chance of inheriting the condition. It is a condition that, by what seems to be the most cruel of ironies, often affects the youngest, fittest and most athletic people in our communities. Those are the facts and I am grateful to the Cardiomyopathy Association for the briefing with which it provided me to assist me and inform me in the debate. I will be happy to pass on the information to anybody who requests it.
I am also conscious that statistics alone do not speak of the impact of the condition on families, nor of the individual tragedies that they represent. Constituents of mine lost a much-loved son and brother because of cardiomyopathy, which had gone undetected in that lively, enthusiastic, fit and talented young man of 19; a young man who was—it seemed—as far from ill health as one could be. At that devastating time, my constituents had to seek out information about the condition, which was not easy to find. Even now, while they are still dealing with their bereavement, they seek to do something positive to help others and to prevent others from suffering a loss such as the one with which they still live.
I believe that it is important to acknowledge the courage not only of my constituents, but of all those who are coping with loss and who seek to drive, influence and support the work of organisations, such as the Cardiomyopathy Association, which seek to create better knowledge and understanding of illnesses and diseases, be that Marie Curie Cancer Care, the Cancer Research Campaign or whatever. Such organisations are full of people who want to create something better for others from their own experiences. I believe, in the difficult times—at home and internationally—in which we live, that we should take succour in the basic goodness and caring for others that we see all around us in voluntary groups and organisations.
My motion contains a simple demand: that there should be a right to automatic screening for all first-degree relatives of those who are diagnosed as having or who have died as a result of the condition. It seems simple; I am led to believe that general practitioners are encouraged to offer such screening, but my constituents' experience speaks volumes about the inadequacies of that encouragement. My constituents, when dealing with the death of their son, had to seek out information. On learning that the condition is inherited, that it could affect others in the family, that it could be detected through screening and that it can be managed if it is detected, they had to fight to have their potentially affected family members screened using electrocardiogram and echocardiogram tests. It is hard enough at any time in our lives to battle for tests of whatever kind, but in the aftermath of a loss such as my constituents' loss, to have to do so seems unacceptably cruel.
In conclusion—I am aware that others have contributions to make to the debate—I seek reassurance from the minister. I seek a commitment from the Scottish Executive that it will examine closely what can be done to provide speedy access to screening for first-degree relatives and to ensure that GPs' knowledge of the subject is improved. I believe that the Scottish Executive should commit itself to consideration of what might be done to raise awareness of the condition and that it should do so in conjunction with the Health and Community Care Committee, the national health service and, in particular, GPs and health organisations, to offer real hope that deaths that result from the condition can be prevented and that families can be properly supported.
I welcome the support of other members in the chamber and I hope that the debate will provide the opportunity to increase awareness of and action on the condition.
I start by congratulating Johann Lamont on securing the debate. I am pleased that she said that she was not totally aware of the condition before it was brought to her attention by her constituents as a result of the sad loss of their son. I can make a similar confession—until the debate, I was not very aware of the condition, but I have done some research and I am surprised by the extent to which the condition affects people. It affects about one in 500 people.
Given the difficulty in pronouncing the name of the condition, I will talk about HCM. HCM is an incurable but manageable condition, although it can lead to sudden, premature death. Systematic evaluation can identify the majority of patients at particular risk. That provides the opportunity for targeted therapy. Treatment can include drug therapy and, in severe cases, cardiac surgery to remove some of the muscle or to insert a pacemaker or converter defibrillator.
Because of the risk of premature death, the Cardiomyopathy Association is campaigning for the mandatory offering of screening to children and young people up to the age of 21 in cases where a first-degree relative has the condition. Diagnosis would require a physical examination and both an electrocardiogram and an echocardiogram. An argument against screening for the disorder is that it is not foolproof, but I do not think that any screening process is totally foolproof.
The CMA is not advocating the screening of all children, or even of all young athletes, who are a key group affected by the condition. The association would like screening to be offered to all first-degree relatives up to the age of 21 of people in whom the condition has been found. That will often follow the tragic loss of a loved one, and there will obviously be concern for the rest of the family.
I do not think that a request to consider the offering of screening is beyond the capability of the Executive; I think that it is very reasonable. Screening should not depend on who someone's doctor is or where someone lives, which unfortunately is, I think, the case. Screening should be open to everybody in Scotland who falls into the category that I have described. I hope that the minister will respond positively to Johann Lamont's call.
I associate myself with Johann Lamont's comments about having expertise on the disease: I find it difficult to pronounce, let alone understand. However, as is the case with many subjects that have been chosen for members' business debates, I have gained an awareness and an understanding of the condition. I hope that the debate allows that to be achieved on a wider scale.
To say that the condition affects one in 500 does not sound much, but when we state that it affects 12,000 people in Scotland, the figure seems more realistic. There seems to be a consensus in support of the Cardiomyopathy Association's campaign to secure screening by electrocardiogram and echo-ultrasound for all first-degree relatives.
I received a letter from a lady in Portknockie, in Morayshire. Her son died of the condition in December 1998. Following the loss of her son, all members of the immediate family were screened, and none had any signs of the condition. Naturally, that lady shares the concern that has been mentioned about familial screening for first-degree relatives. She said in her letter that, had a familial screening programme been available, and had the family been aware of it, she might still have her son today. Having heard that personal point of view, we can understand why people wish to raise awareness of the condition.
Given that the disease is familial, exposing each child of an affected parent to a 50:50 chance of inheriting the condition, the need for first-degree relatives to be offered case testing would seem to be a right, rather than an obligation. The British Medical Association has stated:
"Many patients with hypertrophic cardiomyopathy do not have symptoms and may be relatives of patients known to have the disease. Unfortunately, the first manifestation of the disease may be sudden death, frequently occurring in children and young adults, often during or after physical exertion".
The case of Shona Hill, which is clearly outlined in the information that we received from the Cardiomyopathy Association, indicates the risks and the benefits of screening for the condition. I was shocked to discover how it can affect the members of one family. Shona Hill is a member of the Cardiomyopathy Association and a voluntary co-ordinator. She was diagnosed with hypertrophic cardiomyopathy in her early 30s, while pregnant with her second child, and has been fitted with a pacemaker. As the gene responsible for the condition has been identified in her family, her children have been screened and shown not to carry it, but Shona's father, brother, sister and nephew all suffer from the condition. Tragically, as is too often the case, before the family gene was identified, Shona lost four first-degree relatives at a young age because of hypertrophic cardiomyopathy.
I am pleased to speak in today's debate, because I think that the condition is worthy of our consideration. In seeking to outline the problem and to raise awareness of hypertrophic cardiomyopathy, it is important to remember that the condition will not limit the quality or duration of life for the majority of individuals who are affected, provided that it is picked up and treated at an early stage.
A few minutes ago I picked up the paper that the Scottish Parliament information centre has produced on the subject. I note the question that Christine Grahame asked about the number of deaths over the past five years from hypertrophic cardiomyopathy. The answer was that there were 11 deaths in 1995, 11 deaths in 1996, five deaths in 1997, six deaths in 1998 and six deaths in 1999. The information we have received from SPICe indicates that, if male and female deaths from the condition are added together, the figures are 22 deaths in 1995, not 11; 28 deaths in 1996, not 11; 27 deaths in 1997, not five; 17 in 1998, not six; and 36 in 1999, not six. I do not know whether I am interpreting the information wrongly, but the figures for deaths from the condition seem to be much more dramatic than the figures we were given in the written answer to Christine Grahame's question.
Like others, I congratulate Johann Lamont on raising this issue and on securing today's debate.
This Monday I attended a meeting of the Scottish oral cancer action group. I mention that because my attention was first drawn to the importance and prevalence of oral cancer when the parent of a young man who was a former pupil of mine and who had died of the disease decided to form a group to raise awareness of the condition among the public and professionals. The group that he formed has successfully drawn together many levels of health professionals, including professors and dentists. The group was supposed to meet Mr Chisholm yesterday morning, but at the time he had other things on his mind and the meeting was cancelled.
Some years ago, my attention was drawn in a similar way to hypertrophic cardiomyopathy. Mrs Wilma Gunn, whose son Cameron, a young athlete, died as a result of the condition, decided to put all her efforts into ensuring that Cameron's death would lead to something positive. Johann Lamont's motion mentions that many of the activists in the Cardiomyopathy Association are parents. I hope that we will recognise the value of the work that has come out of their distress, just as we recognise the value of the work that is done by the oral cancer action group. All over Scotland, parents who have experienced such distress have decided to try to turn it into something positive. As Johann Lamont said, our whole society benefits from that.
Wilma Gunn's organisation, Scottish Heart at Risk Testing—Scottish HART—has campaigned for improved screening in Scotland's sports centres and sports clubs, where many of the vulnerable youngsters can be found. She has sought to raise funds for a mobile screening unit and has taken her case to politicians. Indeed, she made a presentation to the cross-party sports group in the Parliament. I will not say too much more about that, as I know that Christine Grahame is particularly interested in Scottish HART.
Today's motion pays tribute to the Cardiomyopathy Association and backs its campaign to secure screening of all first-degree relatives of those who have died from hypertrophic cardiomyopathy. There is a case for widening screening to youngsters who are at risk, in the hope of avoiding the sudden death to which the condition gives rise, with all its traumatic consequences for the families that are affected. There appears to be evidence that similar programmes in other European countries have cut down the number of unexpected deaths among young people. We should not dismiss those claims lightly. I know that the Executive is wary of widespread screening programmes for various reasons, which I can understand to an extent, but I hope that it will consider the proposition carefully.
It must be traumatic to be told the result of a screening test that must change—or is likely to change—one's approach to life. For any screening programme to be valuable, early warning results must be backed up with the appropriate treatment. If necessary, counselling and advice should be offered to those who are found to be at particular risk. As the motion implies, people who are close to the person, who might be worried and affected, also need support.
I support the extension of screening. I hope that the minister will be able to go at least some way towards progress in that area.
I, too, congratulate Johann Lamont on securing tonight's debate. For me, the issue is close to home. Unlike others who had never heard of the condition, I can inform members that my husband has had to live with hypertrophic cardiomyopathy for a number of years. He was always involved in sporting activities. Some members, who know the shape that he is currently in, may find that hard to believe, but he is a former runner and was involved in half-marathons, hillwalking and various other things.
My husband discovered through a routine hospital operation that he was suffering from the condition. That was a life-changing situation for him. The discovery has meant that he has had to reconsider the way that he deals with day-to-day issues such as physical exercise. It has also raised some other issues: suddenly, he was not in a position to get life insurance; his travel insurance would not cover him for going abroad; and he had to go for a medical if he wanted to apply for a new job or take up other opportunities.
My son is one of the lucky ones, because he was screened when my husband was found to have the condition. However, the three or four weeks' wait between the diagnosis of my husband's condition and my son's being screened in hospital were some of the most traumatic of our lives. What were we to do with a football-mad boy, who wanted to be outside kicking a ball around? Since an early age, my son had taken up all sorts of sport and was sport-mad. Were we to keep him in the house, or tell him that he could not play sport? Were we to raise all those issues, potentially inappropriately, or were we to wait for the result? Thankfully, the result showed that my son does not suffer from the condition, but it is important that, when we consider the wider picture, we ensure that those who are close to people who have been diagnosed with the condition are given the opportunity to be screened.
Ian Jenkins hit the nail on the head when he talked about the need to put in place the appropriate supports. I do not know how I would have coped if somebody had said to me that my young child would be at risk. I do not know how he would have coped with having to make decisions about what he wanted to do with his life. My family are aware that we are among the lucky ones. We are conscious that there are many people out there who, having suffered traumatic times, have committed their lives to doing something to improve things.
I hope that the Executive takes the issue seriously. The Executive needs to considers how it can ensure that the availability of screening and treatment is not simply dependent—as in our case—on the individual general practitioner. People need to have that kind of opportunity so that situations are dealt with appropriately.
On the statistics, my husband would probably claim that, rather than being one in 500, he is one in a million for having to put up with me and with everything that I have to do. I am sure that he will be pleased to see that on the record.
Presiding Officer, thank you for allowing me to remain seated. I congratulate Johann Lamont on securing tonight's debate.
I declare an interest: I am a patron of Scottish HART, the Borders-based charity to which Ian Jenkins referred, which is also known as the Cameron Gunn memorial fund. As Ian Jenkins indicated, the organisation was set up by Wilma and Kenny Gunn after their son died from hypertrophic cardiomyopathy some 10 years ago. Since then, Mr and Mrs Gunn have worked tirelessly to promote awareness of cardiomyopathy and to encourage the testing of young athletes.
The Gunns have done that by endeavouring to raise the £0.25 million that is required to provide a mobile echocardiogram that could be used at sports clubs and schools to test young people. The disease is usually more recognisable under the headlines that we unfortunately sometimes read, such as "Sudden Death on Sports Field", "Heart Condition Kills Youth" and "Teenager in Mystery Death".
Cameron Gunn was playing five-a-side football with workmates, practising for a charity game, when he suddenly dropped down dead. He was 19.
As has been said, hypertrophic cardiomyopathy is the largest single cause of death among the under-30s. It is thought to affect at least 125,000 people in the UK, which means about 12,000 in Scotland. Without a heart scan, the condition is difficult to diagnose. Often there is no sign that anything is wrong until the sudden fatality of someone who had appeared to be young and fit. However, with screening, the disease is easily treatable.
I refer Mr Chisholm to a series of questions that I have lodged on this disease. I do not expect answers now, but I hope to get them later. Last year, I asked question S1W-8790 in response to an Executive claim that only 1,000 people in Scotland were affected by cardiomyopathy. Does the minister accept that the figure should be 10 times that amount? The higher figure has been indicated by Professor W J McKenna, who is the professor of cardiac medicine at St George's hospital medical school, London.
In her response to my question S1W-6079, the Minister for Health and Community Care indicated that, under advice from the UK national screening committee and on the basis of current knowledge, Scotland should not offer population-wide screening for the condition. Have we made any progress on that?
I also refer the minister to an Executive news release of 10 April last year, which again stressed that the minister would not consider a national screening programme. The news release contained comments from Professor Stewart Hillis, who said:
"I agree that on the basis of present evidence there is no justification for the introduction of a national screening programme though this should not stop those who feel they are at risk from having access to local screening facilities if they so wish. We are currently piloting work with Sport Scotland where we are examining the value of offering a test or screening to young people taking up competitive sports."
What progress has been made with sportscotland? Will the minister at least consider selective screening for young athletes, sportsmen and sportswomen?
Last year, in the answer to question S1W-4653 on research and funding, I was advised that there were 129 UK-wide research projects at that time. Will the minister provide an update on the current state of research, the collation of that research, and the funding of that research?
Would the minister, or ministerial representatives, be prepared to meet the trustees of Scottish HART, as they have repeatedly requested, in order that they can put forward their views?
Like everyone else, I welcome the chance to debate this issue and I congratulate Johann Lamont on the motion. I fully support the points that she made.
Screening is important to families who find themselves faced with the awful news that they have lost a loved one, a young relative, to hypertrophic cardiomyopathy. I remember, when I was a teenager, losing a good friend. Like all of us, he played on the football field at night. At 17, he tragically died—of a heart attack, we thought. We did not know at the time that it was hypertrophic cardiomyopathy. Like most people, I had never heard of it.
I have a very close friend whose family has suffered from HCM and who have had to live with it for many years. Fortunately, the family have had the benefit of screening. Two out of six in the family have been diagnosed with the condition; they are being treated and they have been able to live as normal a life as possible.
I got to know about the condition through my nephew, Edward Blair, who is a clinical genetic consultant in Oxford. He and his team have recently published a paper on HCM with details of an important gene that they have found that will help develop treatments that will benefit the families involved.
Screening is great and it helps us to treat those who need treatment, but what are we doing with the information that we gather when we screen people? Research into that information is the way forward. In England and Wales, the Government is considering funding four new research projects into the genetic field, but what are we doing in Scotland? Are we funding similar research or will we contribute to those research projects? Screening is important if we want families to be able to live as normal a life as possible, but it is also important that we find solutions to the condition so that the young people who are diagnosed with HCM will know that, when they have families, they might be able to take medication that will allow them to have a normal life without the stress and worry that the condition causes, which Cathy Jamieson talked about tonight.
If the minister cannot tell me tonight what Scotland is doing in relation to research, I would appreciate receiving information on that through the Executive.
I thank Johann Lamont for securing this debate today. I pay tribute to the sterling work of the Cardiomyopathy Association and to Christine Grahame, who has also done excellent work in this area.
Hypertrophic cardiomyopathy is an excessive thickening of the heart muscle without obvious cause. It can strike those who have inherited the dominant gene, even though only minor symptoms have been evident, and lead to tragic and sudden death. As has been said, an investigation such as an ECG might not always detect the condition.
No cure has been found and, of course, further research is needed. It is important that we consider the findings of research that has already been done, not only in the UK, but overseas. The disease is fairly new in that it has been known about only for the past half century. However, a substantial number of families are affected by it. The SPICe briefing says that 16,800 people in Scotland have died of the disease in the past 20 years. Interestingly, 9,500 of those have been women. Perhaps research has to be done into why women are 20 to 25 per cent more likely to suffer from the disease than men are.
It is important that we have screening not only for hypertrophic cardiomyopathy, but for familial hypercholesterolemia, which is another disease of the heart that can strike suddenly with fatal consequences. It has a high prevalence among the south Asian population.
Cathy Jamieson hit the nail on the head when she talked about insurance. The Association of British Insurers does not ask those with a family history to take a genetic test but it requires to be informed if a test has been taken. In that way, the benefits of life insurance might be denied to the families of sufferers. All family members must be screened if those with the condition are to receive treatment. That circle has to be squared if we are to provide justice for families who suffer from the illness.
I pay tribute again to Johann Lamont for securing this important debate and for the way in which she spoke about the McConnachie family in her constituency and others who suffered tragic deaths because of the disease. I hope that the Executive can provide some answers to help to prevent future deaths from this awful condition.
I congratulate Johann Lamont on securing a debate on this most important subject, following the tragic death of a young man in her constituency. I thank all the other speakers, especially Cathy Jamieson for sharing her family's experience of the condition. I also congratulate the Cardiomyopathy Association on the work that it does to raise awareness of the condition among the medical profession and the public.
As we have heard, hypertrophic cardiomyopathy is an inherited condition that involves an abnormal thickening of the heart muscle. Because the thickening occurs in an inward direction, the working of the heart is obstructed. At present, there is no cure for the condition. There is a slight possibility that some drugs can decrease the degree of muscle thickening. Treatment aims to improve symptoms, for those who have them, and to prevent complications. There is no standardised therapy. Various drugs that affect the rate and rhythm of the heart have been used with some success, although those drugs do not necessarily affect the long-term outcome. Similarly, surgical treatment has been of benefit in selected cases.
Recent evidence suggests that the prevalence of the condition is higher than had been thought. It is now accepted that about one person in 500 has the condition. Its clinical course varies markedly from person to person. Some patients have no symptoms at any time during their life. Some have symptoms of severe heart failure. Others die suddenly, often in the absence of previous symptoms. As for the number of sudden deaths among young people in Scotland, the main category is in those below the age of one. In the past 10 years, there have been 16 deaths in that age group. The other peaks are among those aged 15 and 16. Over the past 10 years, there have been eight deaths of 15-year-olds and 10 deaths of 16-year-olds.
I note the points that Mary Scanlon made about the possible discrepancy between some of the Executive's figures and figures elsewhere. I shall look into that and write to her about it. Christine Grahame also raised issues to do with figures and other matters, which I shall look into and write to her about. She asked whether I would meet the trustees of Scottish HART. I am happy to do that. I ask Ian Jenkins to pass on my apologies for having to postpone the meeting to which he referred. I shall reschedule it as soon as possible. Cathie Craigie mentioned research, on which I undertake to write my third follow-up letter, although I know that Susan Deacon recently wrote to Scottish HART about the issue, saying that the chief scientist's office would consider any proposals that Scottish HART produced. None has so far been received, but we would be happy to hear from Scottish HART on that subject.
Any sudden death is a tragic event, but all the more so when it happens to a baby or to someone on the threshold of adult life. I can well understand why there have been calls for some form of screening from those who hope that such deaths can be prevented. The rest of my speech will be divided into two parts: first, whole-population screening and, secondly, targeted screening.
I have two points. First, the information that we have been given refers to prevalence per 100,000 population, which makes the incidence appear considerably greater than the minister has indicated. Secondly, does the Executive have any information on why the incidence of hypertrophic cardiomyopathy appears to have increased substantially during the past 20 years? For example, there has been an increase from 17 cases to 228 cases among males. Is that because of improved diagnosis or because the disease is becoming more prevalent? Do we have any data on that?
I do not have any data on that, but I can look into the matter and get back to Kenny Gibson.
In taking decisions about screening, the Scottish Executive is advised by the national screening committee, which provides independent expert advice to the UK health ministers on the introduction of new screening programmes. The committee will recommend the introduction of a population screening programme only if the natural history of the disease is well understood, if there is a simple, safe, precise and validated screening test and if there is an effective treatment for the patients who are identified as a result of screening.
Having examined population screening for hypertrophic cardiomyopathy, the committee concluded that it could not recommend the introduction of population screening for that condition. That was because none of the committee's key criteria was satisfied: the natural history of the disease is poorly defined; there is no clear definition of the degree of thickness of the heart muscle, as measured by the ultrasound technique echocardiography; and, as I have mentioned, there is no good evidence that treatment will necessarily improve the outlook for those who have the condition but do not have symptoms. As the Executive announced in April last year, we have accepted the committee's advice.
The motion mentions ECG and ultrasound screening of all first-degree relatives of those who die as a result of the condition. We support that approach. We have made it clear all along that we want clinicians to be alert to those people who are at higher risk of sudden death because they have a significant family history of hypertrophic cardiomyopathy. Those people might benefit from advice and treatment. Everything should be done to ensure that the condition is tackled with care and sensitivity. We have emphasised that GPs are expected to refer such patients to a cardiologist for the appropriate investigations. Those patients, and relevant family members, should also be given counselling, including genetic counselling.
Johann Lamont referred to the inadequate encouragement of GPs and asked us to ensure that GPs' knowledge was improved. I will certainly look into that and write back to her.
Recent scientific publications suggest that the use of implantable defibrillators might help to prevent sudden death in high-risk patients with hypertrophic cardiomyopathy. Those initial findings need to be confirmed, but that could be the first form of therapy to prolong survival in such patients. In the light of that new evidence, the national screening committee has commissioned further work and will be considering a report on it next month.
For those families in which a particularly serious form of the disease occurs, the Scottish molecular genetics consortium has been considering the possibility of including tests for hypertrophic cardiomyopathy in its molecular genetic service. That could help with identification of family members affected by the condition.
I fully agree that we should all be working together to raise awareness of the condition, partly among the public but—perhaps even more fundamental—among the medical profession. Johann Lamont and Shona Robison emphasised that GP awareness is critical and, as I said, I undertake to follow up that issue as a matter of urgency.
I again congratulate Johann Lamont on raising an important subject and on ensuring that renewed impetus is given to addressing a most serious condition.
Meeting closed at 17:42.