Main content

Meningitis ACWY vaccine, Testosterone for women, Allotments on prescription, Heart failure and iron

There is confusion about how and when teens should be getting the new Meningitis ACWY vaccine. Plus testosterone for female sex drive and allotments on prescription.

The Meningitis ACWY Vaccine was introduced last year to protect teenagers from year 9 in school to those starting university or college. But there seems to be confusion about how to get the jab and many parents remain unaware of the threat posed by Meningitis W. Inside Health's resident GP, Dr Margaret McCartney takes a closer look at headlines reporting that women should be given testosterone for low sex drive. Plus, half of all people with heart failure also have iron deficiency so might iron be a clue to a new type of treatment? And Mark Porter visits his local patch in Gloucestershire where doctors are offering allotments on prescription.

Available now

28 minutes

Programme Transcript - Inside Health

Downloaded from www.bbc.co.uk/radio4

 

THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

INSIDE HEALTH – Meningitis ACWY vaccine, Testosterone for women, Allotments on prescription, Heart failure and iron

 

Programme 5.

 

TX:  11.10.16  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  FIONA HILL

 

 

Porter

Coming up today:  Testosterone and female sex drive - Dr Margaret McCartney takes a closer look at recent headlines suggesting the NHS is failing women who have lost their libido.

 

Iron and hearts - could boosting levels help the million or so people in the UK struggling with fatigue and breathlessness caused by heart failure?

 

And allotments on prescription - yes, you heard me right - we head to Gloucestershire to discover how gardening has become the latest addition to the local GPs’ formulary.

 

Clip

We had this great idea that somehow you could use gardening to help people sort of get better.  And also some people don’t feel confident about doing gardening, particularly if they’ve had a major illness, so they’re close to the hospital and one great thing about allotments is people have a cup of tea together.

 

I’m not much of a gardener to be honest but I’ll do my best.

 

Porter

More from me and my spade later. But first meningitis and a new jab to protect against Meningitis W. It was added to the national immunisation programme last year and is aimed principally at teenagers heading to college or university.

The job of administering the vaccine has been divided between schools and GPs. But there seems to be some confusion as to who should be having it, and when and where. Indeed in some parts of the country nothing currently seems to be happening - at least for year 9 and 10 pupils who are supposed to be vaccinated at school.

 

And many parents still remain blissfully unaware of both the threat posed by W, and the new jab that protects against it.

 

Who better then to clarify the situation than Professor Andrew Pollard, Chair of the Joint Committee on Vaccination and Immunisation that advises the government on such programmes.

 

Pollard

What happened about five years ago is that we started to see an increase in cases and further investigation shows that the strain that is causing this, the strain of Meningitis W, isn’t the one that we’ve had in the UK over the last few decades but it’s a new strain which appears to have emerged in South America and has been then introduced into our population.  And what’s happening is every year we’re seeing an almost doubling of cases.  Now the last time we saw something like this happen was during the 1990s with Meningitis C and we saw a doubling of cases that happened at that time that led eventually to a very large number of children and adults being affected by Meningitis C, which precipitated the introduction of the Men C programme in 1999.  And that effectively has controlled Meningitis C since then and tens of thousands of cases have been prevented.  So having seen the arrival of Meningitis W we asked the Department of Health to consider an emergency programme to try and stop the same happening as we saw with Meningitis C back in the ‘90s.

 

Porter

So who’s most vulnerable to this new type of Meningitis?

 

Pollard

This new type of Meningitis W that has arrived affects all ages but the group where one of the highest risks is are those who are starting university.  And so the programme has been rolled out to try and protect those who are travelling off to university at the age of 18 and to also catch up the cohorts behind that, so that we’re in a position where teenagers between 14 and 18 eventually will all have been vaccinated and then we can just have a rolling programme of vaccinating children in Year 9 or 10 to ensure that they have already had the vaccine before they go off to university.

 

Porter

And what is it about freshers, people starting university for the first time, that puts them at particular risk?

 

Pollard

One of the reasons why we target this age group is because transmission of the Meningococcal bacteria is particularly common in late teens and early adulthood and we know that is associated with close contact between individuals going to bars and pubs and engaging in kissing and close contact with each other.  And I think particularly important in that is that universities tend to mix people from all different parts of the country so that when they come together there’s more chance of someone who’s never met these type of bacteria before meeting someone who is carrying the organism in their throat.  And the meningitis bacteria are very commonly carried in young adults.  One of the other reasons, apart from the risk of disease in that age group, is that it seems, at least from our experience with Meningitis C, that if you vaccinate teenagers because they have so much transmission going on and the vaccine interrupts transmission in that age group that also starts to block the transmission to everyone else.  And we hope that eventually if we have very high coverage amongst teenagers that that will actually stop the bacteria circulating the population, it’ll actually protect babies and older adults as well as the teenagers themselves.

 

Porter

This is a new programme but there appears to be a lot of confusion, it seems that parents and teenagers themselves aren’t sure where they should be getting the vaccination, GPs’ surgeries don’t always know who’s responsible and certainly schools don’t always seem to know either.  Could you spell out exactly who should be having what and when?

 

Pollard

Well there’s two components to the programme.  The first is the routine programme which happens for year 9 or 10, depending on the school, and those young adults are vaccinated with a vaccine which covers actually four types of meningitis, including Meningitis W, but the vaccine also includes Meningitis C.  And we’ve had a routine Meningitis C programme at that age for a few years now.  And so it’s replacing that Meningitis C vaccine with one that covers C and W, in fact it also covers A and Y, which are two other rarer causes of meningitis.

 

Porter

And that’s done at school?

 

Pollard

That’s done in school, year 9 or 10, as a routine programme.  But because of this risk of W we also wanted to make sure that we’re protecting people going off to university and if we only targeted the year 9 or 10 we wouldn’t be catching that group.  So there’s a sort of a catch up programme over the next few years to also give the vaccine to anyone going off to university.  And that’s being done in general practice.  And so those individuals should be invited by their GP to go and receive the Meningitis A, C, W and Y vaccine each summer and anyone who missed it in previous years and has gone to university, up to the age of 25, if they are freshers are able to have the vaccine as well.  What we’re not offering is – obviously this programme started last year, so if someone went to university five years ago and is still at university they’re not eligible.  And the reason for that is the biggest risk of Meningitis W is for those people who first arrive at university, so it’s really a programme targeted at freshers.

 

Porter

Andrew, let me be clear about this group who are going to university, you say they’ll be invited by their GPs.  We obviously don’t know who’s going to university, are you saying that every 17 and 18 year old will be given this jab irrespective?

 

Pollard

Absolutely.  And that age group is more at risk in general because of the changes in social behaviour that happen in the late teens and early adulthood.  But there is a particularly high risk amongst university students because of close living campuses and so on.

 

Porter

And what should someone do who might have slipped through the net – they’re at university, they’re at their first term in university they’ve not had this – where can they get it from and how quickly would it provide protection for them?

 

Pollard

So if they were in any of the cohorts who should have been vaccinated, in other words starting from last year, then they are able to go to their GP, either their own GP or if they’ve registered at university to the GP at university, and they should be then provided with the vaccine if they have missed it.  Protection from the vaccine should be there within about two weeks after vaccination.

 

Porter

Professor Andrew Pollard. And if you think anyone in your family may have missed out then if they are aged 17 - 25 I suggest you talk to their GP.  And if they are still at school and year 9 or 10, to the school nurse. 

 

But, judging on our experience, don’t be surprised if they too seem confused over who is responsible for what. It seems implementation of the new programme is – well - taking some time to settle in.

 

Now, did you hear this over the weekend?

 

News clip

A doctor who specialises in managing menopausal symptoms has said that testosterone should be offered on the NHS.

 

Porter

And the papers picked on the story too under headlines like this one from The Independent:

 

Clip – The Independent - read

Women suffering from loss of sexual desire should be offered testosterone on the NHS, says doctor.

 

Well the doctor in question is Nick Panay, Consultant Gynaecologist at the Chelsea and Westminster hospital. We invited him in to us here on Inside Health but he is busy in clinic today and appeared rather taken aback by the coverage. It all stems from lectures he gave at last week’s annual conference of the Royal College of General Practitioners. The subject was how to optimise the management of women struggling with the menopause and covered many different areas.  Mr Panay admits to being, and I quote “a little surprised that the only part of my lecture which was reported was the testosterone/libido issue.”

 

In fact what happened was the Press Association picked up on the libido theme, and from there it was disseminated throughout the media.

 

Margaret McCartney is in our Glasgow studio. Margaret this isn’t the first time that we’ve seen comments taken out of context?

 

McCartney

This was like wildfire, so it seemed to be comments that were made in a conference for GPs that were picked up by the Press Association and then seemed to appear absolutely everywhere, it’s like that story grew legs and then bred.

 

Porter

I suppose the headline writers couldn’t resist the combination of sex and testosterone.  Although to be fair from a medical perspective the use of testosterone to boost sex drive isn’t new.

 

McCartney

No it’s not new at all and that’s why I really cannot understand why it seemed to be such a hit with so many newspaper editors.  NICE have said for years if a woman is on HRT and it’s not enough to treat libido then you should consider adding testosterone as well, so that’s been around for ages, it is not new.

 

Porter

The problem we have as doctors though is that there isn’t actually a licensed form of testosterone for women which makes it somewhat tricky, it means it’s an area for specialists only.

 

McCartney

Well it may be, it’s certainly something that I would take a fair bit of consideration before doing but it’s not something that I would never do.  The bigger problem, I think, is the promises that are being made here, so there were quotes saying things like – women were feeling a bit drained and then went on to testosterone and were running marathons, come on libido is a really complicated thing, this is not a situation where you can give a prescription and everything’s going to be alright instantly afterwards.  Now I’m sure there are a few women out there who’ve had fantastically dramatic effects with using testosterone but if you go back and actually look at the studies the studies show that it only makes a very small difference overall.  So on average, compared with placebo, you might get an extra one or one and a half satisfying sexual encounters per month with using testosterone supplements every day if you’re a post-menopausal lady.  And when you consider that the placebo effect in using all these medications is very, very strong, there is a very marked placebo effect usually in all these trials, in the region of about 40 or 50%.  So you have to accept that there’s a lot of other stuff going on here, this is not just a hormonal deficiency.  And in fact testosterone doesn’t dramatically decline at the menopause, it’s something that declines slowly over your life course.

 

Porter

Because there are lots of reasons, aren’t there, why a couple may not be as sexually active as they used to be and I mean hormones may play a role in that but it’s just a small role.

 

McCartney

Yeah it’s part of it.  There’s lots of physical factors, there’s psychological factors, social factors, relationship factors, libido is not straightforward and what I really don’t like is newspaper headlines that seem to kind of imply that if you have a problem with your libido the answer lies in a tablet.  Now for some women that will be true but for many other women it was very, very far from the truth.

 

Porter

If only it were that simple.  Thank you very much Margaret. 

 

Now, time to put on my wellies.

 

Welcome to my local patch.  We’re standing outside the Vale Hospital in Dursley, Gloucestershire but it’s what we’re standing on that’s the reason I’ve brought you here.  Up until a year ago this was a patch of wasteland at the edge of the hospital car park but now it’s been converted into 50 or more allotments.  And what makes them unique is that they’re prescribable.

 

Opher

My name is Dr Simon Opher, I’m a local GP here in Dursley and I also lead on social prescribing.  What you find is patients and doctors gradually are getting this idea, I think, that it’s not just all about pills, it’s about your activity, it’s about getting some exercise, it’s about growing things and we had this great idea that somehow you could use gardening to help people to sort of get better.  And also some people don’t feel confident about doing gardening, particularly if they’ve had a major illness, so they’re close to the hospital.  Actually one great thing about allotments is people have a cup of tea together.

 

Porter

And there’s the all-important shed there of course which I guess is where that sense of community occurs over cake and tea and biscuits etc.  What sort of patients are you expecting me to refer to this scheme?

 

Opher

They may have just had a heart attack and they may love gardening but feel very unconfident about actually doing any physical exercise.  So it’s a way of getting them back into sort of normal life.  Or what happens in medicine is a lot of things that are presented now to GPs aren’t primarily medical in origin, so sometimes this might be something when someone’s actually feeling a bit lonely, they may be mild to moderately depressed but not wanting to go on medicines or anything like that.  And our society, I think a lot of the problems that we need to deal with as doctors used to be dealt with by other people, that could have been the extended family, so mum next door or it could have been the priest, so it might be a spiritual type of issue but they all come to us now in increasing numbers.  And one example of that I suppose is bereavement.  So I think it is really important that we don’t medicalise these issues.

 

Tyer

My name’s Emma Tyer and I’m the founder of the charity based in Gloucestershire for bereaved families.  I set it up following the sudden death of my own husband three years ago.  When you’re bereaved it’s a bit like being catapulted out of one story and into another story.  So the chapter of one book closes and suddenly you’re in a new book.  And everything in front of you is new.  So in order to manage that I found that being out in the garden and working on the land gave me a sense of purpose.

 

Porter

Through a difficult period?

 

Tyer

Very difficult yes.

 

Porter

Was it the gardening or is it the community or a combination of the two – what do you think’s the important part of it?

 

Tyer

It’s all of it.  We get people of all ages to come together, so for example we might have a young boy who’s just lost his mother working alongside a widow who’s just lost her husband and no words are needed but you’re there together working together.

 

Opher

Bereavement happens to all of us at some point in our lives and we feel sad, we feel anxious but we’re not really, we haven’t got a medical problem, this is part of life and I think it’s really important, as doctors, that we don’t give people pills to help them over something, we give them an activity.  And social prescribing has gone up the political agenda, so it’s seen as a good thing to do generally by central government now.  And in fact I think every surgery has access now to a social prescriber and what that means is someone who they can be sent to see, like a physio or a doctor, but they will be given information about non-medical activities if you like.

 

Porter

And what practically do I do – I refer in and then what happens?

 

Opher

Well the next stage is that Amanda, who runs this plot, will meet them – usually on a Thursday morning – and she’ll get them going on the allotment.

 

Porter

These are raised beds aren’t they so I’m quite tall and I quite like digging in this.

 

Godber

My name’s Amanda Godber and I work for an organisation called Down to Earth and I’m coordinating this project.  When you come down then we can spend some time finding a bed that’s right for you, sort of looking at a plan of things that they’d like to grow, suggesting where they can buy seeds from, we can actually source seeds as well, we can help them get started off.  So going through some general sort of rules that we have to have.

 

Porter

What happens if I know absolutely nothing about gardening, which happens to be the case?

 

Godber

It is with a lot of people and when I started I actually planted my onions upside down – I know now…

 

Porter

Can you plant them upside down, I didn’t even know you could?

 

Godber

Yeah, yeah you can and all that happens is the roots come out of the top and the green bit comes out after it.  What we long term hope it’s going to be – it’s a little community – so that people will come down, they know Joe Bloggs is going to be here on a Thursday morning and they’ll sit and have a cup of tea and a chat.

 

Porter

As an observer looking at people that get involved in this sort of project what sort of benefit do you think they get from it?

 

Godber

Obviously you’re getting physical exercise.  Because we’ve done raised beds that can be adaptable, so we could put planks of wood across between two raised beds so they can sit and also they can sit and chat while they’re doing that too.  So you’re getting some exercise, you’re using muscles that you wouldn’t normally use, particularly for elderly it’s really important to keep their hands moving, to keep the grip, and gardening will help with that.  Psychologically being with another group of people.  It’s so special when you grow something and you see it from a seed through to something you can pick and eat, it’s amazing.  And when you’re thinking about that you’re not thinking about other stuff, so that’s one of the most sort of vital things we find, it takes the emphasis off other stuff that could be worrying.  Our first lady through on social prescribing has come through, she had a work related back injury a few years ago, she’s still having physio for that and still has problems with mobility, so her long term aim is to increase her fitness levels so she can go back to work.  But also she’s lost a lot of confidence and feels very isolated because she’s had this injury for a long time.  So shall I take you over to meet her?

 

Porter

Yes please.

 

Godber

Okay, lovely. 

 

Porter

Hi, I’m Mark, pleased to meet you.  So which is your allotment, do you know which one is yours?

 

Patient

I think I’m going to pick one in the middle where it’s all sunny.

 

Porter

Yeah you have the advantage of being first on line I think.  Why were you referred on to the scheme?

 

Patient

I ended up with being in an awful lot of pain with my back and my hip and that was a big shock because I’d always been very physically active.

 

Porter

Well you’re young as well.

 

Patient

Not so young as I used to be but I thought well this would be a really good way for me to start building up my physical strength again.

 

Porter

Do you have a garden at home?

 

Patient

I do, yes.

 

Porter

Could you not do this at home?

 

Patient

Well I could and I do.  The danger there is is that you don’t speak to anybody for the whole day and it’s very easy to just allow your sense of isolation to get really out of hand.

 

Opher

Gardening is one of those areas which actually there’s really quite strong evidence that it really improves wellbeing and it can reduce the number of visits to doctors, for example, there’s also quite clear evidence that it improves mental health scores.  So there’s significant improvements in people’s anxiety and depression ratings.  So when you’re digging, like we are Mark, we stop thinking of the really obsessive thoughts that we have.

 

Porter

Now this is part of the countywide initiative, can you give us some of the other examples of things that are being done?

 

Opher

The commonest one and the most well-known one is general exercise on prescription, so you can refer patients to the gym and they can have 10 sessions of exercise.  But there’s slightly more things coming on stream if you like, so art is another thing, so creativity, there’s also things like walks on prescription where you have supervised walks and in fact we also had a scheme called Salsa on prescription, which was encouraging people to dance and we put on Salsa classes for it, which was incredibly popular.  Interestingly the problem with that was not enough men wanted to do it, so they had loads of very keen women, so we had to induct a lot of men to push them into Salsa dancing.

 

Porter

I always think it funny, I’d see something – one of the advantages of being a GP is you do get to see patients’ homes and I’ve seen allotments that look absolutely immaculate and you go to their house and it’s not quite so immaculate and they spend all their effort on their allotment, I think that’s their pride and joy.

 

Godber

It’s very easy to feel very isolated I think if you’re not at work every day and so at least if you come here it has a huge benefit in terms of the extras that you wouldn’t expect.  It’s like really good medicine.

 

Porter

And it’s different medicine too and I suspect the scheme at Dursley - which allows GPs to prescribe 12 months free use of one of those raised bed allotments - will fill up quickly. More details, as ever, on the Inside Health page of the Radio 4 website.

 

Just under a million people in the UK live with some degree of heart failure, many of whom are iron deficient and anaemic too.  It’s a relationship that has been taken for granted over the years - people with heart failure tend to be anaemic.  But might it provide a clue to a new approach to treatment? Could replacing missing iron help people feel better? A question the new IRONMAN trial hopes to answer.

 

Paul Kalra is Consultant Cardiologist at Portsmouth Hospitals NHS Trust and lead researcher for IRONMAN.

 

Kalra

So heart failure’s a very common medical condition and it’s associated with symptoms such as shortness of breath, fatigue and often patients develop fluid retention – swollen ankles – and the net result of this is that patients often find it difficult to do standard day to day life activities, such as go upstairs, get dressed, have a shower or go to the shops.  And despite advances in the treatment over the last 25 years with drugs, devices and systems of healthcare many patients still remain symptomatic with poor outlook.

 

Porter

The treatment is generally supportive isn’t it, it’s not curative, we’re not looking to fix this, it’s about minimising the impact on their lives?

 

Kalra

Absolutely.  So the fundamental underlying problem is an inability of the heart to pump effectively and there are a number of reasons why that can come about, the commonest in Western societies is people who suffered from heart attacks, blockages of blood vessels, supplying blood to the heart muscle.  But other conditions can cause it, so high blood pressure over many years, problems with heart valves and inherited forms of heart muscle problems.

 

Porter

Using iron therapy in something like heart failure seems an unusual approach, where did the idea come from?

 

Kalra

So around about 15 or so years ago we became interested in anaemia and heart failure and what we’ve found is that around about one in two patients with heart failure have an inability to use iron appropriately and that’s a problem with either absorbing iron or using it in the body, moving it from where it’s stored to where it’s required.  I don’t believe it’s iron deficiency causing the heart failure, it’s heart failure causing the iron deficiency that then causes a real spiral of the syndrome and worse symptoms.

 

Porter

And it’s a vicious cycle because iron is required for carrying oxygen in the blood efficiently, so the heart – that’s one of the heart’s functions – to pump oxygen round the body.  But does it have a direct effect on the heart muscle itself as well?

 

Kalra

Undoubtedly it’s important for haemoglobin, part of the red blood cell, and that’s fundamental to picking up oxygen from the lungs, carrying it round the body and delivering it to all tissues, including the heart.

 

Porter

And put simply if your haemoglobin level is low your heart has to work harder to deliver the same amount of oxygen.

 

Kalra

Absolutely.  However, iron is also a really important factor for all cellular functions, so the powerhouse of the cells is the mitochondria and that produces the energy for cells to deliver all of the tasks that they need to do and iron’s a key component of that.  So the heart itself may pump more effectively as a consequence of improving the cellular function of the heart but that may also be the same for skeletal muscles and we know in patients with heart failure, at least part of the limitation in terms of shortness of breath and fatigue comes from actually the physical deconditioning and changes in skeletal muscles, the big muscles of the legs, the back, the arms that are dysfunctional.

 

Porter

It seems like a really simple but elegant theory that’s behind this.  It seems strange that we’re so far in – decades in – to looking after people with heart failure in quite a sophisticated way and that it’s only just coming to light now.

 

Kalra

I think sometimes when things are so common it’s almost taken for granted and I think this is what happened with the relatively low haemoglobins that we’ve seen and the anaemia that one sees in heart failure.  So 40-50% of patients with heart failure will have a low haemoglobin.  But when things are so common it’s almost easy to overlook them.

 

Porter

They’re regarded as medically normal almost.

 

Kalra

That’s right, so we’ve had a number of small studies that have looked at giving iron intravenously into a patient’s vein and it’s been compared against giving a placebo, which is extremely hard to deliver for our iron’s almost black and the placebo’s clear, so it’s a challenging study to deliver.  But these have been small studies and in the short term patients seem to feel better and can exercise more.  However to become incorporated into routine clinical practice, into international guidelines, we need to evaluate whether in the long term this is an effective treatment, that it’s a safe treatment, it’s cost effective and also that it impacts on what we’d call harder end points here – things such as cardiovascular death and the need to go into hospital, so recurrent heart failure hospitalisations.

 

Porter

And practically what’s involved in giving the iron?

 

Kalra

So this is a randomised study, so patients coming into the study – volunteers – will have a one in two chance of receiving intravenous iron connected to an infusion bag.  It’s hard to bypass the impaired absorption otherwise, so it’s given intravenously.  Otherwise they’ll receive standard care.  And this is the way we establish in clinical practice whether a treatment is effective or not.

 

Porter

Because the conventional approach would be to give people iron tablets but what you’re saying is that we can’t guarantee that these people are absorbing that iron properly?

 

Kalra

If people who are otherwise well develop iron deficiency then oral iron tablets are a very effective way of treating that but in patients with heart failure it’s very hard to bypass the impaired absorption.

 

Porter

So the patients in the trial their iron levels will be optimised and that will vary from patient to patient depending on how much iron they need.  But a typical patient might need to have?

 

Kalra

So this is something that isn’t totally known but we’re anticipating that having corrected the iron deficiency to start with, so that’s with an infusion when the patient comes into the study, we’ll see them then at four weeks and we anticipate around one in two patients will need a second infusion to top them up, if you like.  And then after that when they’re seen every four months we expect they’ll need an infusion of iron probably just once a year.

 

Porter

What sort of impact do you think this might have for a typical patient?

 

Kalra

In terms of a patient’s day to day activity what we’re striving to do is trying to improve the quality of life, maybe trying to maintain independence, it may be doing simple tasks round the house – making a cup of tea or getting out of the house.  And what of course we also hope to show, which can only be done in a large scale study, is see whether it extends the patient’s life expectancy, can it prevent them from coming into hospital and that’s something that patients really want to avoid – a heart failure hospitalisation – the average length of time is around about 12 days and that’s something that we’d really like to impact on.

 

Porter

Dr Paul Kalra. And IRONMAN  is now recruiting volunteers with heart failure to take part in the trial - you will find details on our website.

 

Just time to tell you about next week’s programme - the last in the current series - which, among other things, continues the heart theme with a look at family history and heart attacks. Why the fate of close relatives can have major repercussions for you and your family and what to do about it.

 

ENDS

Broadcasts

Podcast