Journal Club | Vitamin K, Refusal-Related Consequences, and Transfusions with Dr. Shannon Walker

What happens when personal beliefs, patient autonomy, and medical evidence collide?

In this episode of CPF Journal Club, we welcome Dr. Shannon Walker, Assistant Professor of Pediatrics and Pathology, Microbiology and Immunology in Pediatric Hematology/Oncology at Vanderbilt University Medical Center, for a discussion on two emerging challenges facing healthcare providers: increasing refusal of evidence-based preventive interventions and growing requests for directed blood donations based on donor vaccination status.

We begin by reviewing recent trends in Vitamin K refusal among newborns and the potentially serious consequences associated with declining this well-established preventive treatment. We then transition into a broader conversation about patient autonomy, trust in healthcare, and the role of evidence-based medicine as we examine the medical, ethical, and societal implications of directed blood donation requests.

Together, we explore how clinicians can navigate difficult conversations when patient or parental preferences diverge from established scientific evidence, while balancing respect for individual choice with the responsibility to provide safe, effective care.

Articles discussed in this episode include:

Vitamin K Deficiency Bleeding After Refusal: A Sentinel Event in a Misinformation Era.

Trends in Vitamin K Administration Among Infants. 

Directed donations for unvaccinated blood: A departure from evidence-based medicine associated with clinical harm, resource waste, and oversight gaps in a two-year single-center series. 

Recommended reading: 

Legislating Medicine - Directed Donation and the Politics of Patient Choice. 

Medical, Societal, and Ethical Considerations for Directed Blood Donation in 2025. 

Requests for Directed Blood Donations. 

Refusing blood transfusions from COVID-19-vaccinated donors: are we repeating history? 

Parental Refusals of Blood Transfusions from COVID-19 Vaccinated Donors for Children Needing Cardiac Surgery. 

Transcript

SPEAKER_00 0:00

Hey there, welcome to Cumberland Conversations. This is the place where we talk about the issues that matter most to you, your patients, and your community. We're diving into real conversations with real people, sharing insights you can actually use. Let's get the conversation started. Hey everybody, it's Rob Lowe with NOCO Director of the Cumberland Pediatric Foundation, welcoming you to another edition of Cumberland Conversations, our chance to have great discussions with what's going on in the community and pediatric medicine. So I am thrilled to have another episode of our journal club and be joined by Dr. Shannon Walker. And Shannon, take a minute just to introduce yourself.

SPEAKER_02 0:35

Yep. So my name's Shannon Walker. I am a pediatrician at Vanderbilt. I'm an assistant professor in the Department of Pathology and in Laboratory Medicine, where I am an attending on the transfusion genetic service and oversee the learning. And then I am also in the division of pediatric hematology and oncology, where I'm mostly eating ankylic disorders. And then I'm the director of our benign hematology research program where I oversee clinical trials for our uh patients with leading function.

SPEAKER_00 1:05

So you were not busy at all. You know, sorry. Okay, good. So anybody who needs some help could reach out to I want to give a shout out to one of uh your colleagues, Jeremy Jacobs, who we are going to tear apart his paper today. He's actually one of the authors of a couple of these. Um but he was very kind. Unfortunately, he was not able to join us today because of other commitments, but uh was really helpful by email and actually threw out a lot of articles that we could have discussed, and we may throw those in the show notes for folks that want to look at those. Um but this all started at a March uh issue, or excuse me, I think it was May, yeah, May issue of pediatrics uh perspectives article written by Jeremy colleagues about vitamin K deficiency bleeding, uh, which is very timely, saying more and more of that. And we can talk about the incidence of that a little bit. Um, but why don't we lay the groundwork first? Check a minute and just talk about what it is, how prevalent it is, what we're looking for in the three different sort of types in the time frame.

SPEAKER_02 2:05

Yes, exactly. So vitamin K deficiency bleeding uh is a disease that is exclusively seen in the neonatal population. Um, since 1961, the AAP has recommended that infants get uh the vitamin K injection um at the time of birth. Um, after they infants were developing um, you know, severe hemorrhage complications down the line that were improved in patients who've had this this injection of vitamin K. Um, vitamin K is a um a nutrient. Um it is uh something that is found in adults that we get through our diet, um, that we get through some of our gut flora, um, but in the neonates that are um breastfeeding that don't necessarily have high levels of vitamin K and who don't have kind of the mature gut flora that adults do, they can be deficient in this um kind of supplement that helps develop some of your clotting factors. Um, and so your vitamin K-dependent clotting factors are your factors two, seven, nine, and ten. And if you don't have enough vitamin K, you're not going to be able to produce those clotting factors to levels that are going to be helpful. Uh, and so there are three different flavors of vitamin K deficiency. Um, the first is kind of early onset vitamin K deficiency. That's mostly seen in moms who are on medications during the pregnancy that can affect your vitamin K development, the seizure medications and those sorts of things. Um, it's not seen quite as often, and we're kind of more aware to look for it in those moms, and we can kind of correct vitamin medicine. Um, the seizure medicines. I think one's the older seizure medicines that are not used as often. Um have kind of the what the actual name of it is. Um we see it between uh your first day of life and kind of seven days of life. That's more your early onset vitamin K deficiency. Um, that's fairly rare as well. That's usually in patients who have more kind of um more metabolic metabolic deratements and those sorts of things. And then what we see is kind of your your classical vitamin K deficient bleeding is um presents from one week of life up to about four to six weeks of life. Um it's most often seen in exclusively breastfed infants, um, and it can present kind of with catastrophic hemorrhages. So we see intracranial bleeding, bleeding into the brain, uh, we see GI bleeding that can be devastating and kind of everything in between. And it can be very subtle, it can be can be quite challenging to detect until you have a color.

SPEAKER_00 4:41

Until they're not, yeah. The change is pretty appropriate.

SPEAKER_02 4:43

Exactly, exactly.

SPEAKER_00 4:44

So wonderful. Okay, so we've been doing this since 1961, but obviously there's been a kind of a change in messaging and information that's out there that's wise people to be a little more resistant. And it's more of a broader mood to understand that. But it's pretty impressive. I think we go from just under 3% refusal rates to now we're pushing to five to six percent. But I think some of the papers really say we don't know if it's more prevalent than that because you know there's not an ICD 10 code or way that's really documented well.

SPEAKER_02 5:11

Yes.

SPEAKER_00 5:12

Uh so a lot of things we we don't know. Do you have any data that it might be higher than that?

SPEAKER_02 5:15

Or I think just kind of um, you know, personal uh information. I've tried to kind of look into some of our rates of vitamin K refusal um at the at Voma, et cetera. And there's not a specific ICD 10 code for you know vitamin K refusal. And so it is a little bit challenging when you're trying to compile the data to really know the numbers of of kind of refusal there. Yeah.

SPEAKER_00 5:42

But pretty significant. I mean, 80, I think it was 81 times higher risk of reading when you refuse that. Yes.

SPEAKER_02 5:49

Are you involved much uh regularly in the consultation of these babies or so I have talked with um some of the the direct the medical directors of our newborn nursery, they're the ones who really I think see the most of it and are having most of these conversations. Um and I know that um in the the article in pediatrics, one of the things that they suggest is kind of starting the conversations earlier, you know, throughout the pregnancy and then continuing those through the newborn nursery and then with your kind of regular pediatrician as well. Um it's hard to just have kind of one conversation with someone, you know, who may have seen, you know, very scary information on social media or you know, someone who has a very personal story that they're telling them about why they shouldn't get it, uh, and really being able to have kind of the time um and really just uh, you know, personal conversations to really address those concerns is really hard to do with just one visit at the time in the newborn nursery. And so I think it's important to kind of really set the stage for for these as well.

SPEAKER_00 6:51

Well, and I I have a little theory about that too, that I think that what's changed over the last 20 years plus since I was practicing is um you used to have that kind, that I mean, premier pediatrician was the one going to the hospital. And especially your second or third babies, you knew them, you trusted them, you had conversations. Now in the day, it's like after hospital medicine and new ones, yeah. You know, these are different people. They work for the hospitals, and there's not that same level of connection or trust. And I I think that's part of it. So you know, part of that I think is pediatricians. We need to make sure we're talking to our moms who are pregnant in pre-natily, or if it's a science where it has the discussions about some of these things like we do with vaccines in the clinic. Oh, they they have a sense of clarity about that. What about on the back? Let's say we identify these folks and uh we have concerns. You know, I I think the paper makes that case for getting the back end early to the pediatrician. What's that window that is is most beneficial to prevent late onset? Is it any time in the first couple of weeks? It's anytime.

SPEAKER_02 7:55

Yeah, there's not a specific window. It's not something where if you don't get it at that first day of life, you've missed the boat and you're not able to get it after the fact. Um, I do know that I've talked to some of the kind of community pediatricians through the Vanderboat system who are able to have some of these more nuanced conversations with their patients that they have a relationship with. Um, and then the question comes to well, who who stocks the vitamin K? How are we able to get that if they change their mind later at some point? Some of these um being able to anticipate some of these things that come up if you have a a family that maybe changes their mind after a two-week visit, are we able to kind of get that to them and make it easy and smooth and able to in the moment be able to offer that for them as well?

SPEAKER_00 8:42

Yeah, and and just anecdotal uh there was a back order of the diagonal chemical practice control order resize. Is that something you had seen or if you're reading about it? I think it's difficult for chemophactors to try to manage that. Right. You know, it might be erratic, it's not used to storage and ordering, all that becomes an issue. But uh okay, so let's I'm talking to just for a second in this because so many people will ask about oral vitamins. And we talked about that briefly, you touched on it. It it's not regulated as part of constantly what you're getting if you recommend it, correct?

SPEAKER_02 9:16

And that's something that comes up a lot with families who are hesitant um to get the injected vitamin K. Why can't we use the oral version? The oral version is available in multiple European countries. So why is that something that we typically recommend here? I think there's a lot of uh differences between what is available in the European countries and what we have here. There's not an F-regulated vitamin K that we can feel confident knowing exactly how much is in there with what we're recommending. Um, there's not a maternal supplement that we could give that can boost vitamin K levels in the breast milk because you have to have such high levels of vitamin K because just nothing that's commercially available at those levels. Um, and so I think that that's the problem number one is we don't actually know what these infants are really getting. Um, there are different um dosing regimens that the European countries use in terms of um, do you give the dose daily? Do you there's a three-series dose that you give? Um, but a lot of that comes down to compliance. Um, and you know, as we were saying in the hospital system here, where you might be seeing someone different in the newborn nursery, you might be seeing someone different for your initial check, you might be seeing someone different down the line just based, you know, provider availability, um, and really ensuring compliance and those sorts of things gets to be a little bit um complicated as well. Um, we tend to not see late onset vitamin K division bleeding in our formula-fed babies. Um, it's typically seen in exclusively breastfed infants. Um, and there is vitamin K in formula. Uh, but the thought is that you're getting that with every feed, every day, multiple types a day. And so, you know, the compliance is less of a concern because it's just automatically there preemptive. Exactly. Exactly. You don't have to think about it, it's already happening. Yeah.

SPEAKER_00 11:11

And we talked about this briefly. It's all about education and how we, you know, try to help our patients and families make the best decisions. Uh, I always try to keep my algorithm spicy. And so I always kind of follow, you know, try to follow what's out there, what people are saying. And we've talked about this briefly. There's not a great answer to this as far as data and things like that, but people say it's if this is a perfect system you'd evolutionary or God's plan or things like that, that there should be no need for this. This is supposed to be perfectly designed. But there's some things we don't know. And uh, Red Submit and talked about, you know, vitamin K Ris and Wilson may be uh a plan, and that is that uh, you know, they there may be a little bit for lack of a better term, hypocoagulability and embryogenesis and development that isn't necessary. And uh and you know, there there's trade-offs in every kind of evolutionary uh development. So we don't know that, but I but I think that's a way to kind of think, you know, maybe it is the best plan laid out. It's just we have to deal with the pros and cons of each.

SPEAKER_02 12:16

Yeah, yeah. I think it might be one of those where it's it's the best that we have with the information that we have. I see a lot of patients in my um pediatric hematology clinic for other deficiencies, other concerns, and those sorts of things. Um, and a lot of them don't have a normalized hemostasis system until they're closer to six months of age, also, um, unrelated to vitamin K. They got their vitamin K injection, but they may have other things going on. Um, and you know, how do we how do we manage that? How do we monitor that? Um, you know, there's a lot of nuance there. Um, I hear from a lot of um patients and even some other providers that um after about eight days of life, your coagulation system has normalized. Um, but that's not what we see when we see patients in practice when we're checking other labs. Well, um for some archaeemothilia patients or other bleeding disorder patients that may end up not having those, we still don't see normal, you know, coagulation numbers until they're a little bit older. Um so I do think that the eight degrees maybe come a little bit more from historical reasons rather than like actual coagulation and hemostatics.

SPEAKER_00 13:24

Yes, that's interesting. So I guess the way to look at it is like every there's gonna be weakness to everyone. Right. And so what we want to do is is even though the numbers are small, give everyone a chance that they just are if it's orbited by a keg giving it shot at Farth. Um we want to try to do that. Right.

SPEAKER_02 13:41

And I think partly because the bleeding could be so catastrophic. It's not, you know, it's not something that necessarily could be easily treatable with you know antibiotics or something like that. A head bleed could be devastating. I mean, the example in that paper was a patient who who ended up passing away. And we've seen patients with long-term orologic deaths due to intracranial bleeding. Um and so it's not something that is going to have the potential to um really affect somebody's life and and what they're able to do down the road. And so I think, you know, in pediatrics, we always want to give our patients uh the best chance that they can for a normal healthy light spend. So um that's why, you know, we think that vitamin K is important.

SPEAKER_00 14:28

Yeah, I sort of varied the head. The paper started with a with a terrible story of one child who presented at several weeks of age. And although we were able to quickly reverse the damage was done. The damage was already done and it was too late. And that's again, it goes back to their fine until they're and uh so there are some positives here though, just for pediatricians, that just because they refuse in the nursery to you know continue, just like you talk about having those conversations with vaccine uh hesitancy, is you've still got a window in the office to try to save that. Right, right.

SPEAKER_02 15:01

And I think just things that you know I've I've discussed with um providers in the newborn nursery and some of the things that that we hear frequently, um, you know, it's really not a that's it's not a vaccine. It gets kind of lumped together with your you know initial hepatitis B vaccine, um, with some of the odd eye profile that you get. Um and I think people think injection equals vaccine, but it's really just a vitamin. It is a vitamin that we're giving in an injected form to really set patients up for success. So um it's it comes up as vaccine hesitancy, but I think that you know, if we could just reframe it as you know, a vitamin injection, maybe that might be.

SPEAKER_00 15:48

They don't think about that differently.

unknown 15:50

Right.

SPEAKER_00 15:50

Um, so yeah, and there was a uh opinion letter uh Jeremy sent along. It was from uh I think uh January of 2020 next week. By the way, I love an hematology two pages and three pages, very easy to read. So hit the eye on yeah, I'm on board. That's great. And that's even with like the figures, and that was awesome. I was able to even I could understand that. So that's wonderful. So again, uh we appreciate having you all available for uh consults and things like that. Jeremy said along another article I think we need to discuss. Uh, and it goes along that same line has the team or this is from one that a lot of us don't have on our bookshelves, but transfusion medicine, I believe. Is that the correct uh title? I think it's transfusion medicine. This is, I believe, a little bit older. This uh no March of 2026, I believe it was. Again, this takes where you found some right stuff. Yeah, so uh, and this was about directed donations for unvaccinated. Specifically, we're talking about COVID, right? And that's where most people have developed a fear of maybe circulating RNA or spike protein or things like that, and this the side effects of that. And a lot of people requested directed donations of vaccine free blood, sometimes from family members or things like that. Uh, but that causes triple life. It causes the stress of the system and significant delays. And I think the idea of the paper, this was a two-year study. I believe most of this was done at Vanderbilt, over there were other authors. Uh, and there were 15 total uh that requested directed blood. Nine of these were um well, first of all, let me throw it to you. Is how is this a growing problem? Have you heard more about this?

SPEAKER_02 17:38

Yes, and I think reflected in the article as well. I think they found um four or five patients, you know, in the first year that they evaluated who had received these directed donation units. Um, and the following year they had 11 or so in more than double from one year to the next. And I do think that we um in the blood bank in transfusion medicine are are handling some of these requests a little bit more frequently um and trying to, you know, help as we can with the clinical teams, provide uh resources in terms of you know how we feel about drug donations and those sorts of things.

SPEAKER_00 18:14

Yeah. And it is a concern that you're hearing, is it like let your album get lecocarditis or is it just I don't want that virus in my system?

SPEAKER_02 18:22

I think that there's a variety of concerns. I think that a lot of people um would are comfortable receiving blood products um, but would prefer those blood products, you know, that they know it comes from someone who maybe hasn't had a particular vaccine, such as COVID. I think that's the main one that people are worried about. Um, you know, our blood supply is incredibly safe at this point. Um, you know, the viruses that were problematic in the blood supply in the late 80s and early 90s, HIV, hepatitis C are screened for multiple times after the donation process. Yes, but I think that it's uh, you know, it's something that has been there for a long time that people kind of have concerns about. It's in our consent process and those sorts of things. Um, there's not uh anything right now that um with the blood suppliers that either can ask the question for donors whether they've had certain vaccines, um, whether you know it doesn't test for that as part of the screening process. And so um, I think that that in general makes some people uncomfortable with the blood products that they might potentially be receiving. Um and so to kind of work around that, they say, oh, you know, my mom or my friend, I know that they have vaccine, you know, I'll use their blood instead. Um and so that's kind of the process and what people are.

SPEAKER_00 19:45

It is mostly if you're the vaccine because they've had COVID.

SPEAKER_02 19:48

They've had the natural vaccine, which is hard to in clinical practice to it separate the antibodies from you know, uh the vaccine versus natural infection. And I don't think that there's anything that's clinically available that can do that.

SPEAKER_00 20:02

And I think it made the point in the paper that a directed supply may be actually less safe.

SPEAKER_02 20:08

Correct. We actually in transcription medicine discourage directed donations because we consider them to be less safe. Yeah. Studies have shown that patients often are less um truthful on the screening that we use um when you're going to donate blood. There's kind of an initial um questionnaire that kind of you know make sure that that the donor is eligible. Um, and so that if people feel maybe a little bit more pressured to go through with the donation for someone that they know or that they're you know trying to do, they may not be as truthful on that questionnaire as they would be just for you know a general volunteer into the donor pool. Um, and so there are higher rates of disease that come out of the testing from directed donors compared to kind of volunteer donors.

SPEAKER_00 20:55

So I think that's an important point. Then there were some issues, especially from family members donated blood. There's like increased adverse outcomes like graphic hooks, things like that. Is that talk about that?

SPEAKER_02 21:10

Yeah, yeah. So that's really something that we see as well. So family members often have similar kind of HLA antigens on their blood uh cells, and so that can be passed through a donation. Um, so we typically, for all directed donations from family members, recommend irradiation, which is a process that stops any sort of white cells that might be replicating that may have gotten through the filtering process. Uh and so that would reduce the rates of transfusion associated graph versus host disease, which you can see more from family donors because the HLA profiles are similar. And so the system gets kind of confused a little bit easier than it would if it looks completely different from another donor. Um, if patients are ever to also have um need a transplant in the future, so for some of our oncology patients. Who might be looking at a stem cell transplant down the road that makes sensitize their immune system to potential donors in the future that may not end up being acceptable for them down the road because they've already kind of seen these antigens screws through donation there as well.

SPEAKER_00 22:17

And that goes to the point that that is an extremely complicated, kind of numinous discussion in these kind of where I think so many times it's just like, okay, if you want to do it, you need the blood, it won't be right.

SPEAKER_01 22:27

Right, right.

SPEAKER_00 22:28

Let's move on. So the delay in that process to the risk factors really needs to be part of that discussion. Yes. That being said, I think that even inside the Vanderbilt system, we don't have the best protocol set up. We don't have a cook. I think that compared to Seattle, it may also. So we don't have a protocol based, is what you're saying. And how we discuss at it and how in a community hospital, how to address that because you have really more limited district.

SPEAKER_02 22:57

Um and I think I I enjoy seeing the framework that was kind of proposed within the article in terms of how we can um, you know, protocol as the process more and have some of these conversations. I think some of it is a timing issue. So if patients come in acutely ill, they're on new diagnosis of they have some sort of trauma, um, they are going to need a blood transfusion quickly. Um, then directed donation is not really going to be an option for them. And so I think that that's easy conversation for clinical teams to say, hey, if we need this before next week, it's not going to be something that we can help coordinate. Um, I think that, you know, there's a process with our blood suppliers. So we at Venevolt and Donor Center. So we are um dependent on our blood supplier, which is primarily through blood assurance. Um, and then we get some some blood from the Red Cross and from some other kind of smaller suppliers, um, they can free a directed donation. Um, they do that within the framework of a general kind of donor volunteer situation. Um, so it would be taking resources away from a potential volunteer donor to do this directed donation as well. Um, and then depending on the the kind of protocol at the donor center, um, it they may go through the whole questionnaire, they may go through all the infectious disease testing, they may not. Um, it's donor center dependent on how they do that. Um, and so if the units are able to be used, it depends on whether they've kind of done through that whole process. Um, I think the community hospitals is an interesting question. Um, I certainly think that we have put together some resources from transfusion medicine side of things in terms of, you know, some of the risks with directed donation and the increased rate of infectious disease, um, you know, the transfusion-related graph resistance, why we worry about that. Um, there are some nuances in terms of blood type and who is going to be appropriate. Um, you know, we typically think of our blood type in terms of red blood cell transfusion. Um, but when you're thinking about plasma or platelets and the circulating anti-A and anti-B antibodies that are there, it may not be the exact same type that you're looking for. Um, and so if you don't have a good kind of background on that, that might be a little bit confusing as well.

SPEAKER_00 25:21

Well, and I think it's just important to remember that there are transfusion services. I mean, I think it's funny, I still hear people that talk about, oh, I do transfusion medicine. I was like, oh, you're a hematologist. Yeah. Well, I actually am both.

SPEAKER_02 25:32

Well, unnecessarily.

SPEAKER_00 25:33

Yeah. Yeah, but I think there's the you forget there's a whole specialty that can help you in these issues and things like that. So great stuff. It really goes back to these are very complicated sessions, and uh, we need to have as much information and relay it. You know, there's so much, especially when we talk about there was so much information. We talk about other spike protein and RNA that persists three years vaccination, you know, all these things that really clinically don't mean much, but it gets lost in all kinds of ways and it confuses people. So we really have to do the translator. And we're trying more and more to do a better job of that. But this is something with that we're learning how to do this because 20, 30 years ago we just didn't do that very well.

SPEAKER_02 26:17

Right. And I think sometimes when we're talking about these uh, you know, families who have requested directed donation, um, a lot of times, you know, they're they're talking with their surgeons or with the anesthesiologists who may not have the same background in the blood system as we do. And so how can we find a way to help them, whether that's you know, provide education to those services, provide information that they can provide to the families, you know, do we need to have some more things that are that are written and prepared and those sorts of things to have those conversations? Um, you know, I think that that's really important. Um, I did like in at the other sites and kind of the framework that they have, um, they also had ethics involvement because I do think there's some ethical questions um in terms of are you taking resources away from the general blood pool to go to certain people? Um, and is that ethically, you know, the right thing to do? I think that that depends. And so I think having the ethics team involved to help with some of those more nuanced conversations are reasonable as well. There are things that we can do to try and prevent blood loss, you know, during surgery. There's things we could do before surgery to kind of optimize someone's hemostatic system. And so having that as part of it as well, I think is it's important to try and how can we improve a patient's ability to tolerate a surgery? So maybe they don't need the transfusion, um, as opposed to always just kind of jumping and saying, you know, we need this particular unit for X, Y, and Z reasons.

unknown 27:52

Perfect.

SPEAKER_00 27:54

Well, Dr. Wolf, thank you so much for coming to talk about these papers today. I think this is is valuable information and uh just reinforces the idea, especially the first paper, vitamin K is good. Yes, please need and if there's actually, you know, uh don't give up because there's still a window in the first few days. We need to have good communication from hospitals to the care provider duty to document it's better, but from a co-coding standpoint, and making those communications to the private care pediatrician of family friends and you know, it may need to help practices stock in their offices, or have some you know, well-defined process for if you know and you as the pediatrician are having these conversations, you know this family better than anyone in the medical system.

SPEAKER_02 28:40

How can you easily get that for the family if you're able to have those conversations? There's such a role, I think, for for the primary care physicians in in that way to really just be able to take the time to you know sit with these families and address their concerns and then also have a way to get them vitamin K if they decide that's routed.

SPEAKER_00 28:59

It all starts with trust, it's where we build the trust of the medical home, and hopefully that makes the difference. So wonderful. Well, thank you again, and thank you to everyone who's watching, listening. Uh certainly if you have any questions about this episode, uh, we're happy to forward questions along to Dr. Walker or Dr. Jacobs. Uh and if you want to hear any more about imatology or any topics, please let us know. Shoot us an email at CPF Asheville. That's cpfashville at email.com. Uh we're happy to try to get your concerns of our episodes. Or we may come in and do it. Okay. All right. Well, thanks everybody for watching, and uh, we'll see you again soon. Take care.

SPEAKER_01 29:42

Thank you for joining Cumberland Conversations. We're proud to support the people who care for Tennessee's children. Don't forget to subscribe so you never miss an episode and stay connected with CPF for more tools, trainings, and community updates. Until next time, take care.