Gail Roboz, MD: 20 units is definitely lower than what I'm doing and I'm curious of what my colleagues are doing. Rami, what kind of, is there a number or how do you make the decision. This is again a lower risk patient and what Azra said, somebody who's not going to have a giant risk for a GI bleed or renal problems. Somebody who would be a candidate for it, how, do you have a number or a theory?

Rami Komrokji, MD: Of course, everybody should have a number or a theory. So, I totally agree with Azra, I think first that it's important to track the transfusions, because most of the studies such as the 15 - 20 units, you start getting the iron overload. The caution in MDS is also that like you know, and I think published on this years ago that one-third of the patients with MDS without transfusions will have a serum ferritin more than 1,000, so it's an acute inflammation reactant. So, you have to look at the ferritin in the context of the transfusions they had. Then goes again to the points like, do you believe in chelation or not and I think proving the benefit is a little bit tough in MDS. Several retrospectives for respective observation that showed survival, the only one to my clinical trial could not just go for all survival so I tended to be an event free survival. At the end, you have to make your assessment, do I believe that the patients would benefit from chelation. I think if somebody is lower risk and going to be living for several years, they may have sequela of iron overload. What I do, is I cutoff individualized things again. Like first, once they get to the 20 units of blood, I would look at their serum ferritin. By the guidelines, for example, the MDS foundation states that if they are above 1,000, you consider the guidelines of 2500. I have to have my own criteria, so I put them somewhere in between. But, it’s really like seeing the trend and what is the patient's response to the treatment I'm doing. Are they going to be just on blood transfusions, or I will have a window of opportunity or the patients have improvement in their count and then I discuss with them? I think the downside of this thing that we have to keep in mind, that those treatments are not side effect free. There is some toxicity from the treatments we prescribe. Especially in elder patients, if somebody is in their 80's, and I'm an adding chelation that could affect their kidney functions and they will get into renal, I just to weigh that into the equation. But in general, yes, once they above 20, especially if I don't see that we are getting to a time where we are responding, their serum ferritin on more than one time, not just acute reaction is more than 1500, I will start thinking of it, individualizing it based on the side effect risks for that particular patient.

Transcript edited for clarity.