Calcium Disorders&Parathyroid Disease
September 19, 2013
Calcium is a mineral that the body needs for good health and healthy bones. It is also critical for the body’s normal functioning. Calcium is naturally found in some foods, or can be taken as a nutritional supplement. When the body has too much or too little calcium, calcium-related problems can occur. This can be due to improper calcium intake or the inability for the body to regulate calcium levels properly, such as with parathyroid disorders.
The parathyroid glands regulate calcium levels in the body. Parathyroid disorders may cause a loss of energy, kidney stones, depression and many other symptoms.
Calcium-related medical problems include hypocalcemia, vitamin D deficiency, kidney stones and osteoporosis. These disorders can have devastating effects on your health and well-being. Diagnosis and treatment are key to managing these conditions, and will help to control symptoms and decrease the risk of other related complex problems.
About the Speakers
Susan Williams, MD is an associate staff physician in Cleveland Clinic’s Endocrine Calcium Clinic in the Endocrinology & Metabolism Institute, an associate professor of clinical medicine at Cleveland Clinic Lerner College of Medicine, and an assistant professor of clinical medicine at the Wright State University School of Medicine. She is board-certified in internal medicine, nutrition, obesity medicine, and bone densitometry by the American Board of Internal Medicine, the American Board of Obesity Medicine, and the American Board of Physician Nutrition Specialist.
Dr. Williams completed her fellowship in clinical nutrition and metabolism at the Cleveland Clinic following a residency and internship in internal medicine at Kettering Medical Center, in Kettering, Oh. She graduated from medical school at Wright State University School of Medicine, in Dayton. She completed the U.S. Air Force internship in clinical nutrition, and served as an officer, nutrition professional and reservist in the U.S. Air Force. Dr. Williams obtained her master’s degree from the University of Rhode Island in human and clinical nutrition. Dr. William’s specialty interests include bone and mineral metabolism, metabolic bone disease, calcium disorders, malabsorption and malnutrition in adults, and medical bariatrics. Dr. Williams sees patients at Cleveland Clinic Main Campus.
Krupa Doshi, MD is an associate staff physician in Cleveland Clinic’s Endocrine Calcium Clinic in the Endocrinology & Metabolism Institute. She is board certified in internal medicine with a specialty in endocrinology, diabetes and metabolism. Dr. Doshi completed her fellowship in endocrinology at Cleveland Clinic after her residency and internship in internal medicine at Saint Luke’s/Roosevelt Hospital Center in New York. She is a graduate of the medical school at University of Bombay, Seth G.S. Medical College, in Bombay, India. Dr. Doshi’s specialty interests include parathyroid and calcium disorders, osteoporosis, metabolic bone and skeletal problems, thyroid cancers and disorders, and diabetes. She currently sees patients at Cleveland Clinic Main Campus.
Let’s Chat About Calcium Disorders and Parathyroid Disease
Pilatesgirl: What are the blood tests and their meanings for parathyroid disease, including calcium ranges, parathyroid ranges and vitamin D ranges?
Krupa_Doshi,_MD: Parathyroid levels with normal or low vitamin D levels are suggestive of primary hyperparathyroidism. Different laboratories have different reference ranges.
Patti: My parathyroid lab reading was 73 (high, but not very high). My blood calcium was normal. Do I have secondary hyperparathyroidism that needs treatment? My doctor didn't seem concerned about the high number.
Krupa_Doshi,_MD: Low vitamin D levels can cause elevation of PTH (parathyroid hormone). I recommend that you have your 25-hydroxy vitamin D levels checked.
Pilatesgirl: My sister has hyperparathyroid disease, and my family has a history of bone health issues. We have a father and grandfather with multiple myeloma, a nephew with cartilage cancer and another nephew with noncancerous bone tumor. Do you think there is any relationship to these health issues? I also have celiac disease. Has anything been discovered about genetic propensities to these issues?
Krupa_Doshi,_MD: It is hard to say, your sister may have hyperparathyroidism because of low dietary calcium or low vitamin D levels. Hyperparathyroidism is not usually autoimmune. However, celiac disease is autoimmune in nature and can cause secondary hyperparathyroidism because of vitamin D malabsorption. I am not sure if the bone tumors in your family are related. You may want to see a geneticist for further evaluation.
GEOVEL: My (parathyroid hormone) PTH is elevated, but vitamin D and calcium are in the normal range. I have had numerous scans, blood work and 24-hour urine test with negative results. I did have a kidney stone two years ago, but do not have kidney disease. I also have osteoporosis. My internist and I continue to be puzzled about the increase in the PTH and diagnosis of secondary parathyroidism when the tests have not shown any abnormalities. What could be causes behind the continued elevation?
Susan_Williams,_MD: Elevated parathyroid can occur for a wide variety of reasons, but sometimes we see primary hyperparathyroidism even with normal calcium and kidney function. You may benefit from seeing one of our experts in the Endocrine Calcium Clinic to have your laboratory test results and other tests reviewed. Perhaps we can help figure out what is going on.
jcecys47: I was diagnosed and treated for thyroid cancer when I was 20 years old. My thyroid was surgically removed and, in the process, at least one of my parathyroid glands was ‘accidentally’ removed. This caused me to be calcium supplement dependent for the past four years. I was wondering if there are any preventative steps I need to be taking in order to protect my bones and prevent osteoarthritis or osteoporosis? Are there any medical tests I should be doing? Is this even something I should be worrying about in this point in my life? Since I am a young adult cancer survivor and medical professional. I would really like to prevent any further medical diagnoses if I can.
Krupa_Doshi,_MD: You are saying that you have hypoparathyroidism, i.e. your parathyroid gland (s) is not working to keep your calcium at a normal level. This can be a problem if not taken care of. Long-term problems include memory issues and bone loss to name a few. I would highly recommend you see a specialist to get a full evaluation and for ongoing care. Laboratory tests should include calcium, phosphorus and vitamin D evaluation. If you take too much calcium with hypoparathyroidism, you increase your chances of developing kidney stones.
Parathyroid Tumor Diagnosis
Pilatesgirl: What do you think causes parathyroid tumors?
Krupa_Doshi,_MD: Most of the time we do not fully know what the cause is. Sometimes these are related to genetic problems.
nanlin2002: I have read on National Institutes of Health PubMed website (www.ncbi.nlm.nih.gov/pubmed/) that an undescended parathyroid tumor often does not show on a sestamibi scan. Is this so, and why would a sestamibi scan not be able to detect an undescended adenoma?
Krupa_Doshi,_MD: A sestamibi scan sometimes does not pick up even descended adenomas. That is why it is not used to diagnose hyperparathyroidism. It, like most other imaging studies, is not perfect.
Low Bone Density: Diagnosis and Treatment
Alegro13: What medical examinations should be done for teens and young adults that have normal thyroid exams, but have a low bone density scan?
Susan_Williams,_MD: We do not normally do bone density tests on teens and young adults since peak bone mass is not achieved until the age of 18 years old or after. Also, many individuals will have low bone mass but this may be normal for that individual. But there is more to consider than just low bone mass—and that is something called bone quality. Many of us have 'low bone mass,' but the bone is healthy and strong due to good nutrition, routine physical activity and overall good health. Remember, DXA (dual-energy x-ray absorptiometry)—how we measure bone density—is really meant to be used to measure the bone density of postmenopausal women and men who are over the age of 70 years old, as well as those who have underlying disease that puts their bones at risk.
Patti: Is Forteo® is the only drug that increases bone density? My understanding is that all the other current medications for osteoporosis merely prevent further loss of bone density.
Krupa_Doshi,_MD: Your understanding is correct. All of the other current medications for osteoporosis merely prevent further loss. Forteo® is only drug that increases bone density.
Effects of Hypercalcemia
hilo323: Please explain high calcium in sarcoidosis and its effects on the body.
Krupa_Doshi,_MD: High calcium can cause an imbalance of other minerals, memory issues, calcification of soft tissues and dehydration. Kidneys will also start excreting high amounts of calcium in urine, increasing the risk of kidney stones.
fbd2: My wife has been diagnosed with hypercalcemia. A few years ago tests determined that the extra calcium was being deposited on her heart valve seats. Several doctors have been trying to solve this problem of too much calcium. She found one doctor who was willing to try surgery. In July, she had surgery to remove one of her parathyroid glands. (It is possible, but questionable, that two other parathyroid glands were removed about 20 years ago when she had surgery to remove half of her thyroid gland). The surgeon felt the operation was successful, but found that the gland he removed was not as enlarged as he would have suspected. Right after the surgery her calcium level dropped to a normal range. However, at her two-week check up and blood test, the calcium level was back up to pre surgery levels. She drinks a large amount of milk, and daily takes something like 10 prescriptions. What would you suggest her next step should be?
Susan_Williams,_MD: My first suggestion is that she does not overdo drinking milk. Two or three small glasses of milk daily is sufficient; and, yes, there is such a thing as ‘too much of a good thing.’ However, there can be other reasons for elevated calcium besides hyperparathyroidism. Your wife’s list of medications, as well as her diet, should be reviewed by one of our experts. In the meantime, caution is advised in that it is possible to drink too much milk or other dairy products.
Vitamin D Deficiency
JudyfromNJ: My question is regarding vitamin D deficiency. My 40-year-old daughter has not been well for two years, and was told that she has a vitamin D deficiency. She originally was put on a large dose for one month to bring the levels up— and they did improve. However, she didn't realize that she needed to stay on the supplement and the levels became abnormally low again. They put her back on 1000 mg per day, and she had her levels checked. Her vitamin D level is still too low, so they doubled it. Why is she so deficient in this, even when she is taking a supplement? Could she have some malabsorption issue? She is a vegetarian, and has been tested for celiac disease, since my sister has it, but the test was negative. She has constant musculoskeletal pain, is very fatigued, and has shortness of breath. She has been seen by every specialist including an endocrinologist who checked her thyroid and said all was normal. Her calcium levels are normal. Her life has changed drastically.
Susan_Williams,_MD: Vitamin D deficiency is very common and not something that will just go away. Sometimes it is necessary to take up to 5000 IU of Vitamin D3 or more daily in order to achieve and maintain normal blood levels. While some individuals can take 1000 IU, others need much higher doses. However, once an individual is deficient, usually a supplement is needed for the rest of his or her life. It may be beneficial for her to be seen by one of our experts in the Endocrine Calcium Clinic to help determine the correct dose, and to see if there is anything else that we need to help address.
nanlin2002: I have read that a low level of vitamin D can be the result of parathyroid disease, i.e., the parathyroid is keeping the vitamin D level down as a way to keep calcium in check. Can this happen?
Susan_Williams,_MD: Let me see if I can clarify. Low vitamin D can result in elevation of the PTH (parathyroid hormone). When the vitamin D is low, it can result in inadequate absorption of calcium and when that occurs, the parathyroid takes action to make sure there is adequate calcium in your blood. So, it is important to have adequate vitamin D, as well as adequate calcium, daily.
Dietary Intake of Calcium
Xomue: How much calcium does an elderly woman who is 73 years old need each day, assuming she's getting enough vitamin D? She has osteoporosis and a thyroid problem that requires daily dose of Synthroid® (levothyroxine) 88 mg.
Susan_Williams,_MD: We recommend 1200 mg of calcium daily that comes totally from your diet. Then, if need be, from taking a supplement. Think of it this way—lots of foods have some calcium within them. If you eat an average American diet, you will get about 300 mg of calcium daily without even trying. If you have three servings of dairy such as milk, cottage cheese or yogurt, you will easily meet the 1200 mg recommendation.
Patti: How much calcium does a 73-year-old woman with osteoporosis (-3.2 spine bone density) really need each day? The Harvard University nutrition center website says that new research indicates that one serving of dairy plus about 300 mg of calcium from food is all that one needs. It also states that more than that could possibly increase fractures.
Krupa_Doshi,_MD: The Harvard Nutrition Center website actually states that we still do not know if we have established an adequate level of calcium in dietary intake. They use examples of fracture rates in other countries, such as in India where people have lower fracture rates in spite of low calcium intake. However, one must also consider that people in these countries have more sunlight and more physical activity.
I would recommend that you use the NOF (National Osteoporosis Foundation) website at nof.org/articles/542 - to get an idea of how much calcium intake is adequate. The information is by experts from multiple leading institutions and do not reflect a single center review.
Xomue: New research posted on the Harvard University website shows that, if you have osteoporosis, 800 to 1000 mg daily calcium is adequate if you get enough Vitamin D. In fact, more calcium can have a negative effect and cause more fractures, according to this one site. Are you aware of this research, and if so, can you please evaluate it for me? Also, my relative has a dairy intolerance. What should she do (she is elderly and has osteoporosis).
Krupa_Doshi,_MD: It is true that excess calcium can be harmful. Aiming for a limit of 1000 mg/day is a good goal. Nuts, green leafy vegetables, avocado and broccoli are good sources of calcium. Some brands of non-dairy milk are fortified by vitamin D.
fbd2: Can dietary changes help lower your calcium level?
Krupa_Doshi,_MD: Generally speaking, no.
Supplements: Calcium and Vitamin D
tabialex: What is the current calcium and vitamin D dosages for a 71-year-old female with osteoporosis? (My lumbar spine T Score is -2.8, right femur total -1.8 and left femur total -1.7.) Does the amount of calcium recommended include dietary calcium?
Krupa_Doshi,_MD: I would suggest using the National Osteoporosis Foundation website (nof.org) to get easy-to-understand official guidelines about calcium and vitamin D dosage recommendations.
eatveggies: I am a 67-year-old female diagnosed with hyperparathyroidism after having slightly high blood calcium levels for many years. A sestamibi scan prior to surgery showed one enlarged parathyroid gland in the lower left thyroid area. It was removed during surgery along with the left thyroid lobe, which contained a large indeterminate nodule (found to be non-cancerous after surgery). My serum calcium levels have been normal (9.4) since my surgery that was done in June 2013. I was told to check the PTH (parathyroid hormone) and calcium levels again six months after surgery to be certain that there is no further hyperparathyroidism. I take 250 mg magnesium (Nature Made brand) three or four times per week because my serum magnesium levels were low, and vitamin D 1000 mg once per day since that also was low. I take one or two 750 mg Tums® each day for gastroesophageal reflux disease too. When is the best time and how should I take these supplements for maximum absorption? What are the chances that more of the parathyroid glands will become diseased later on?
Krupa_Doshi,_MD: Tums® must be taken with food, and no more than one serving size at one time. Vitamin D is best taken with the biggest meal of the day for best absorption. The dose does not have to be divided. There is a 10 to 20 percent chance that the problem may recur.
tabialex: I am taking 3000 units of vitamin D daily, and my level of 25-hydroxy vitamin D is 33 ng/ml. Should it be higher?
Krupa_Doshi,_MD: There is no harm in targeting levels to be in the 40 to 60 ng/ml range. 80 ng/ml is the upper limits of normal in most laboratory tests.
Xomue: What is the optimal blood level of vitamin D3? The normal range is 30 to 70 ng/ml, but what is optimal? What is the goal to shoot for?
Krupa_Doshi,_MD: The optimal level for vitamin D3 is 40 to 60 ng/ml.
resykl: I took a vitamin D supplement in the past, and it was prescribed again after my parathyroid surgery. When my calcium was too high again, I was told to stop the vitamin D supplement. Would that have been to prevent absorption of too much calcium? Should my vitamin D levels be monitored along with calcium levels?
Krupa_Doshi,_MD: Yes, to both questions. Once your high calcium levels are corrected again, you will be probably be advised to take the vitamin D supplement again.
tabialex: What is the current information regarding calcium taken as a supplement or in the diet with subsequent deposit in the arteries? I am concerned because of my family history of coronary artery disease. Are there studies that show vitamin K2 prevents calcium deposition in arteries?
Krupa_Doshi,_MD: There is no data to support that appropriate calcium (diet +/- supplementation) in adults causes calcium deposition in arteries. There are no studies to show that vitamin K2 prevents calcium deposition in arteries.
Side Effects of Medication for Calcium Levels
Sue in WDC: I am a 67-year-old woman with paroxysmal atrial fibrillation (a-fib) and atrial flutter. I'm on Cordarone® (amiodarone), and my thyroid numbers are at the top of the normal range. On recent EKGs, my QT interval is either borderline or somewhat prolonged. I read somewhere that calcium and potassium play a role in QT prolongation. Can you could talk about calcium's effect (if any) on the heartbeat—especially the QT interval. Currently I aim for 1200 mg of calcium in my daily diet.
Krupa_Doshi,_MD: As long as the blood calcium level is in the normal range, it should not affect the QT interval. Amiodarone commonly causes thyroid dysfunction and I would recommend you have your thyroid tests addressed by an endocrinologist soon. Hyperthyroidism can contribute to atrial fibrillation and this must be ruled out.
Parathyroid Gland Surgery
paulakk57: My husband has been told he has a spot on his parathyroid gland. His doctor wants him to go to a specialist in Chicago to have this looked at. His calcium level is not inflated. After reading so many things regarding parathyroid tumors, I am confused about this. Should he actually have surgery to correct this problem? Is it really a problem?
Susan_Williams,_MD: Good question! There are many reasons why a parathyroid gland may look abnormal and yes, it is possible to have an overactive parathyroid even with normal calcium and normal PTH (parathyroid hormone)—odd as this may sound. We look at a wide variety of things when considering parathyroid surgery, such as bone density (yes, even in men), kidney function and history of kidney stones, just to name a few. Consider having your husband come to Cleveland Clinic’s Endocrine Calcium Clinic, where we see patients with similar stories every day. Sometimes surgery is necessary, but sometimes it is not!
Parathyroid and Calcium Levels After Surgery
Carissaeg: What should I do if I still have high parathyroid levels one year after I had my surgery? My levels will not stabilize. One month it is normal, and three months later is abnormal.
Susan_Williams,_MD: Sometimes this does occur. It is important to have an expert look at not only the PTH (parathyroid hormone) level but also other functions, such as kidney function, that can affect parathyroid levels. Similarly, sometimes it can be due to a deficiency such as vitamin D, or sometimes even dietary protein. But before you consider self-treating, please make an appointment with one of our experts in our Endocrine Calcium Clinic. Bring your laboratory work with you—and let's see if we can help figure this out!
resykl: Should I avoid dairy foods? I've had parathyroid surgery, but my calcium is still too high. I am used to drinking two or three glasses of milk a day, eating cheese and yogurt. I have been told by every heath professional with whom I've consulted that dietary changes would not help lower my calcium level.
Susan_Williams,_MD: We recommend not avoiding dairy products after parathyroid surgery, but there can be many reasons why the calcium is elevated. Medications, supplements or other underlying conditions can all cause elevated calcium. What we do recommend is to get about 1000 mg of dietary calcium daily. This is equivalent to three 8 oz. glasses of milk daily. Do not hesitate to come see us at the Endocrine Calcium Clinic. We would be glad to lend a hand in helping to figure this out.
Treatment and Exercise for Low Calcium (Hypocalcemia)
tabialex: Since I could not tolerate oral bisphosphonates, I was prescribed calcitonin nasal spray, which I no longer use. I have been advised to start Reclast® (zoledronic acid). I would appreciate your opinion on this medication. Also, how much would weight-bearing exercise help my lumbar spine T score?
Krupa_Doshi,_MD: Reclast® is an excellent option. Other great options that you can explore with your doctor are Prolia® (denosumab) and Forteo® (teriparatide). Exercise is an excellent non-pharmacologic way to prevent fractures. It will help your bones, even if it does not translate into an improvement in your scores.
Bone Strengthening Exercise
Patti: Because of feet problems, I am unable to do much standing on my feet for long. Is there any alternative to weight-bearing exercise? What is the best physical therapy-type exercise I could do to prevent fractures of the spine?
Krupa_Doshi,_MD: You may want to try resistance exercises, such as resistance weights, upper arm weights and water resistance exercises.
Experimental Treatment for Parathyroid Disease
nanlin2002: Do you use radio-guided surgery at Cleveland Clinic to surgically treat parathyroid disease?
Krupa_Doshi,_MD: We do not use radio-guided surgery for parathyroid disease.
Hypothyroidism Diagnosis and Treatment
moonstruck: I have been diagnosed with hypothyroidism about a month ago. For eight years I was subclinical with normal FT4 (free thyroxine), FT3 (free triiodothyronine3) and TSH (thyroid stimulating hormone) level of around 20. I had no symptoms during that period, so I did not treat it. Recently, I had a reading of a low FT4, normal FT3 and TSH of 64. My only symptoms were a puffy face and some swelling. I was given 25 mcg levothyroxine and waited one week to start because I was seeing an endocrinologist. Within a week my TSH shot up to 94, so I started levothyroxine. In two weeks my FT4 was normal and TSH dropped to 32. At five weeks the FT3 and FT4 moved up more, but the TSH is still at 32. Why was there such a drastic climb in one week and a drastic drop in two weeks with the TSH? Also, I have felt so much worse since starting levothyroxine. I have days where I almost feel hyperthyroid and the dose is too much, then days I feel hypothyroid again. I do not like the ups and downs and how it makes me feel. I feel so unnatural now. Why I am I feeling this way?
Krupa_Doshi,_MD: TSH is a very sensitive hormone, so even minor changes in levothyroxine will cause large swings in TSH. When a person has been hypothyroid for a very long time, then even small amounts of thyroid hormone can sometimes make them feel like that might be too much. So, slow dose escalation may help. An occasional patient reports feeling hyperthyroid when they take the levothyroxine all at once, but feel better by dividing dose into a twice-per-day dose.
moonstruck: If your thyroid is still working somewhat, does the dose you take supplement the thyroid—or does it completely shut it down, and is being replaced only by the amount of hormone you are taking?
Krupa_Doshi,_MD: Supplements only do not shut down the working thyroid.
moonstruck: What would happen if I stay a bit more hypothyroid for awhile? I do not want to be hyperthyroid. I have too much anxiety now that I never had before.
Susan_Williams,_MD: There is no advantage to doing so. Taking your thyroid medication as prescribed, getting the blood tests done to see if a dose adjustment is needed, and following up with your doctor are essential components of the management of this disease. Being frankly hypothyroid can cause constipation, weight gain, slowed heart rate, undesirable skin changes, hair loss, and other metabolic abnormalities that can be harmful.>[?
moonstruck: So, if only supplements and the dosage a person needs depends on how much the thyroid is still working then? Is that why dosage is different for other people?
Krupa_Doshi,_MD: Yes. It also depends on how much they weigh, how they take the medications and what other medications they are on, which can influence the dosage.
Moderator: The hour has gone fast. I'm sorry to say that our time is now over. Thank you, Dr. Doshi and Dr. Williams, for taking the time to discuss calcium disorders and parathyroid disease. Your answers were very detailed and personal.
Krupa_Doshi,_MD: Thank you very much for asking such great questions!
Susan_Williams,_MD: I would like to thank all of you for your excellent questions. It is clear to me that there are many folks out there who really care about their bone health and their health in general—thank you for that. For those who still have questions or who need an expert in bone, calcium and parathyroid, don't hesitate to make an appointment to be seen in our Endocrine Calcium Clinic where my colleagues and I would more than happy to see you.
To make an appointment with Krupa Doshi, MD or Susan Williams, MD in our Endocrinology & Metabolism Institute at Cleveland Clinic, please call 216.444.6568 or call toll-free at 800.223.2273, ext. 46568. You can also visit us online at www.clevelandclinic.org/endocrinology.
For More Information
On Thyroid and Parathyroid Conditions
On Cleveland Clinic
Cleveland Clinic’s Endocrine Calcium Clinic addresses problems associated with the regulation of the body’s bone, mineral and hormone functions.
The Endocrine Calcium Clinic within the Endocrinology & Metabolism Institute provides access to a multidisciplinary team of experts who specialize in treating the range of common to rare calcium disorders. An on-site DXA bone density scanning laboratory tests for calcium and bone diseases, and infusion center for administering medications.
Cleveland Clinic’s endocrinology services are ranked first in Ohio and second in the nation by U.S.News & World Report.
On Your Health
MyChart®: Your Personal Health Connection, is a secure, online health management tool that connects Cleveland Clinic patients with their personalized health information. All you need is access to a computer. For more information about MyChart®, call toll-free at 866.915.3383 or send an email to: email@example.com.
A remote second opinion may also be requested from Cleveland Clinic through the secure Cleveland Clinic MyConsult® website. To request a remote second opinion, visit eclevelandclinic.org/myConsult.
If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link clevelandclinic.org/webcontact.
This information is provided by Cleveland Clinic as a convenience service only and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. Please remember that this information, in the absence of a visit with a health care professional, must be considered as an educational service only and is not designed to replace a physician's independent judgment about the appropriateness or risks of a procedure for a given patient. The views and opinions expressed by an individual in this forum are not necessarily the views of the Cleveland Clinic institution or other Cleveland Clinic physicians. ©Copyright 1995-2013. The Cleveland Clinic Foundation. All rights reserved.