Sammita Satyanarayan, MD,

Multiple sclerosis (MS) is an autoimmune disease where your immune system attacks your central nervous system, including the optic nerve, the brain, and the spinal cord. This can cause serious neurological symptoms, however the field has undergone advancements in recent years with more therapeutic options available to prevent disease worsening.

In this Q&A, Sammita Satyanarayan, MD, Assistant Professor of Neurology at The Corinne Goldsmith Dickinson Center for Multiple Sclerosis at Mount Sinai, explains some of the symptoms of MS, how doctors diagnose this condition, and the unique services offered at Mount Sinai.

What are the symptoms of multiple sclerosis?

There can be a lot of different types of symptoms with multiple sclerosis. MS is a disease where a person’s immune system starts going after their own brain and spinal cord. There’s inflammation that can sometimes build and leave a scar in the brain or spinal cords. Those scars are called lesions, and we can see them on an MRI. Not all areas of inflammation necessarily cause symptoms that people feel. It’s sort of like traffic. If you have a small fender bender on a quiet neighborhood road, that might not cause you any type of traffic delay, since you can just go around it and there’s plenty of ways to get to the main road. But if you have that same type of accident on a crowded highway during rush hour, you’re definitely going to feel that traffic delay. In a sense, that’s sort of true for signals going through our brain and spinal cord. There are areas of the brain and the spinal cord that are more like neighborhoods and some that are more like highways. With MS, these delays affect our sensations, our actions, and our thoughts.

Can you give an example?

The symptoms of MS depend on where the inflammation actually is. Some people can have painful vision loss if the disease involves the optic nerve, which takes visual information from the eye to the brain. Some people can have inflammation in the spinal cord, and that can sometimes affect the sensation or strength in your arms or legs, or could affect urination, bowel movements, or sexual function. People can also have lesions in their brain, and that can cause symptoms like numbness or tingling in their face, trouble with dizziness or balance, double vision, and even sometimes trouble with cognition or memory.

What does it mean if you think you have symptoms like this?

There are a few important things to know about symptoms in MS. First, not everybody is guaranteed to have all of these possible symptoms. In fact, some people only ever have one. New MS attacks don’t usually have symptoms that come and go over the course of just a couple minutes or an hour. They usually worsen over days to weeks at a time before getting better. This is for the type of disease that most people get, which we call relapsing-remitting MS. It’s important to say that symptoms can improve over time. MS treatments these days have gotten really good, and while they do not fix any prior symptoms a person has, they are very good at preventing any new symptoms.

How do you diagnose multiple sclerosis?

MS is a life-changing diagnosis. And unlike other diseases, there isn’t one blood test that we can run and make the diagnosis. Therefore, doctors must be careful and comprehensive in our approach. We want to make sure that a person’s symptoms actually fit with MS, and want to make sure that we’re excluding other diseases that either don’t need treatment or need different non-MS treatments.

So what is involved?

We use different pieces of information to convince ourselves that this is a disease that’s happened in multiple places over multiple time periods, hence the name of multiple sclerosis. The types of information we use to assess this includes clinical symptoms, MRI, sometimes blood tests to rule out other diseases, and sometimes spinal fluid. With clinical symptoms, we look to see what’s affected. We look at what has happened over time with symptoms. We do a physical exam to see if we can find signs of injury to the nerves. We see if all those are consistent with what we expect in MS or if we get inflammation. We look at imaging and not just to see if there something on the MRI but we’re looking to see if there’s something specific for MS on the MRI. We look at the shape, the orientation, the location of what we’re seeing on the MRI to see if that characteristic of MS. We don’t have a blood test for MS, but there are times when we use blood tests to rule out other diseases. Lastly we sometimes use a bedside lumbar puncture, also called a spinal tap, where we look at the clear spinal fluid that surrounds the brain and the spinal cord. If there are signs of inflammation in the spinal fluid that are not in the blood, that can suggest there’s an inflammatory process in the brain or the spinal cord. But it’s just one piece of the puzzle. We are trying to fit all of these pieces together, and to do that we use an internationally approved set of diagnostic criteria to be able to actually make the diagnosis of MS.

What is unique about The Corinne Goldsmith Dickinson Center for Multiple Sclerosis at Mount Sinai?

The Center, located at the Icahn School of Medicine at Mount Sinai, treats MS as well as other neuroimmunologic disorders. One of the things that makes this place special is the people. We have doctors who are deeply invested in all aspects of doctoring, whether it’s taking care of people, doing the cutting-edge research that helps advance the field, or even educating the next generation of doctors about MS. There are neuropsychologists who are learning more about cognition because we know that’s important to our patients. We have a group of nurse practitioners who are dedicated to the care and the well-being of our patients, as well as social workers and administrative staff who help people with getting the resources and medications they need.

How does the Center help patients live their lives?

One thing that is unique is the Center’s focus on the whole person. Despite all our advancements, our treatments are preventative. They help you for the future, but they don’t necessarily help with how you feel right now. That’s important, because while a big part of our job is to make sure that things don’t get worse, we also want to see people feel better. We know it takes a village to get there. We work with your diet, sleep, exercise, and mood because we know this affects your energy, strength, and cognition.  And we know we have to find the best ways to help people not just survive, but really thrive. Our patients are not just defined by having MS. They’re defined by all the other things that they’re doing in their lives that are so important, and we want to keep them doing that.

What kind of research is being conducted in MS?

We are involved in a lot of different kinds of research at Mount Sinai, and we’re always looking for anyone who wants to get involved with that effort, such as participating in clinical trials. That’s how we push the field forward. Everything we know at this point in time about all the therapeutics available for MS is there because there have been people before us who have been willing to give their time to MS research. We’re involved in a lot of different types of clinical research. For example, we are participating in a clinical trial that’s testing a new kind of therapy for people who have progressive disease. We are involved in longitudinal research projects, which is where people don’t have to take a medication; they help us by monitoring their disease and their symptoms over the years, which helps us better understand MS as a disease. Unique areas of research at our Center include understanding the impact of MS on cognition, the role that diet might play in MS, and understanding the role of the gut microbiome. My research interests have been understanding how social disparities of health can actually impact access to care and even disability, both within MS and Neuromyelitis Optica Spectrum Disorder. It’s really important to think about, because in addition to learning how to treat people better, we want to make sure that we’re understanding how social and economic factors in a person’s life can also affect disability.

How can someone get involved with this research?

We’re also always looking for people MS or other types of conditions, or even people with no medical problems at all, to be involved in research studies. So if you’re a person with MS or a person without MS and want to get involved with our research, please reach out to one of the physicians at our Center or call or connect to talk to a research coordinator and see if you’d be eligible for any of our studies.

A nationwide shortage of infant formula has caused anxiety for parents across the nation as local and national agencies and private industry work to improve supply.

“Understandably, this has been a scary and concerning time for parents,“ says Morgan Howard, RD, CDN, a certified clinically advanced nutrition coordinator for the neonatal intensive care unit at The Mount Sinai Hospital. She encourages parents to use their pediatrician as a resource, and offers some helpful answers to the questions they have now.

My local stores don’t have the baby formula I usually buy. What should I do?

In most cases, any standard infant formula should be safe and appropriate to feed your baby. There are some circumstances where a specialized or particular formula is needed—for example if your baby has a severe allergy or another medical condition. If this is the case, you should consult with your pediatrician before changing brands or formula types. But these are rare instances. Even if you are using a sensitive formula or a reflux formula, you should be able to switch to a standard formula that is available to you. It is okay to switch between brands. Most brands are very similar, and your child should tolerate differences between them. Store-brand formulas are also a perfectly safe option for your kids, and in fact, most store-brand infant formulas are the same, with only store-specific labels.

You want to look at a variety of local stores and smaller stores in your community for any availability. You can also use store websites to show you in-store availability before going to multiple stores. Be sure to reach out to your child’s health care providers if you are having trouble finding infant formula, as they may have other tips to help. They also may give you further information to help you find the best options for your child. If you use WIC to obtain your formula, please reach out to your WIC office, because they can also help with tips and formula availability.

Can I dilute the baby formula to make it last longer?

Diluting baby formula is not recommended. This is not safe, because it will water down the key nutrients in the formula that your child needs. Watering down formula can cause dangerous abnormalities in sodium or calcium levels in the blood. We also don’t recommend any homemade infant formulas, as these are going to be missing vital nutrients for your baby. We know that this is a challenging time to try to find infant formula, but sticking to the available options in your stores is going to be the best choice for your infant.

Is it okay to give my baby milk? If so, what kind?

During this time of need, the American Academy of Pediatrics is allowing for children six months and older to have some whole cow’s milk, only for a brief period of time, if formula isn’t available. The recommendation is to have no more than 24 ounces of your child’s feeds coming from whole cow’s milk, and not using any low-fat milk or skim milk. It is important to stick to whole cow’s milk, because, of the cow’s milk options, this will best meet your child’s needs. This should be for as brief a period as possible, because it isn’t typically recommended for this age group, but a few days should be okay for your child. Cow’s milk is low in iron, when compared to infant formula, so it is important to follow up with your pediatrician if this is something that you are doing, since additional supplements, especially iron, may be needed. If your child is eating solid foods, try to give some iron-fortified solid foods, like cereals or other iron-containing sources

What about donated breast milk?

Some families may also consider using donated breast milk. If you are considering this, the safest option is to obtain the milk from a certified milk bank, as this milk is pasteurized, tested, and known to be safe for your child.

How did this baby formula shortage happen, and what is being done?

The shortage has occurred for a few reasons, including supply-chain issues related to COVID-19, changing demands for formula, and, unfortunately, a recent recall of infant formula from a large formula manufacturer, which has significantly affected the amount of formula available for families to purchase. The government and formula companies are working together closely to try and resolve this issue. They are flying in formulas from overseas. The government is helping companies do whatever they can to increase formula production to try and provide more formula for your children. One large facility that was closed is now shortly going to be reopened, which should help increase the supply in the next six to eight weeks, first starting with specialty and allergy formulas for children who can’t otherwise tolerate standard formulas. Then the next step will be to increase the amount of standard formulas being produced so there should be more available for your infants.

Is there anything else parents need to know about the shortage?

We understand that this is a concerning time for parents. You should use your pediatrician as a resource. Many pediatric practices and local communities have made efforts to secure formula that may be available by donation. Any time you are getting formula from somewhere other than a retail store, it is important to make sure that you’re taking unopened, unused formulas that are not expired and also not part of the recall. The makers of infant formula offer support sites and hotlines that may be helpful to parents. And more information is available from the American Academy of Pediatrics, the U.S. Department of Health and Human Services, and New York State.

One in eight people in the United States over age 12 has hearing loss in both ears, according to the National Institute on Deafness and other Communication Disorders, and many younger people are now experiencing problems.

At the same time, only one in five who would benefit from a hearing aid actually uses one. And people with hearing loss wait an average of seven years before seeking help, according to the Hearing Loss Association of America.

“Individuals of all ages could benefit from testing, hearing aids, medication, and other treatments,” says Bess Nagler, AuD, CCC-A, clinical manager of audiology at the Center for Hearing and Balance at Mount Sinai. “Often it is a family member who encourages the person with hearing loss to finally come in for an evaluation.”

Bess Nagler, AuD, CCC-A

The number of people who have difficulty hearing is expected to rise dramatically in the coming decades. Age-related hearing loss usually begins around age 60. However, Dr. Nagler notes that many patients seeking evaluations are in their 40s and 50s.

“We are seeing a younger demographic coming into the office for a hearing exam. The emphasis today on sound quality with respect to music and Bluetooth streaming has underscored this trend,” explains Dr. Nagler. “At Mount Sinai Doctors Faculty Practice, we are also seeing an increased awareness about the importance of testing.”

Types of Hearing Loss

Complications with the physical structure of the ear, the nerves, or the connection between the inner ear and the brain are often the genesis of hearing loss. The three categories are:

• Conductive hearing loss occurs when a problem in the outer or middle ear prevents sound from reaching the inner ear. Some causes include ear wax, middle ear fluid from a cold or allergies, acute or chronic ear infection, foreign body, or a perforation in the eardrum. Medication or surgery can often help this type of hearing loss.
• Sensorineural hearing loss occurs due to a problem with the inner ear or the nerve pathway to the brain. Inner ear hair cell damage that occurs as we age is the most common cause. Some other causes include genetic conditions, loud noise exposure, ototoxic medications, tumor on the acoustic nerve, or illnesses. Hearing aids can often help this type of hearing loss.
• Mixed hearing loss is a combination of both conductive and sensorineural hearing loss.

A common pattern of hearing loss is hearing in the normal range in the lower frequencies, but fading out to a more significant hearing loss in the higher frequencies. “In these cases, you can hear people talking but are unable distinguish every sound or word,” says Dr. Nagler. For example, high frequency sounds include consonants such as the s, f, th, and k. These sounds give speech clarity. When you miss these sounds, you need to rely on context or lip-reading (difficult with a mask!) to fill in what is being said, which can be exhausting over time, and difficult when people are wearing a mask. “Individuals often withdraw from the conversation completely, which can be very frustrating for them and their families,” Dr. Nagler says

How Hearing is Evaluated

Having your hearing tested is simple. First, the audiologist will look inside the ears to see if there is wax, fluid, or infection. Then, an objective middle ear function test is performed, measuring energy transmission through the middle ear. Finally, the audiologist will ask you to identify a variety of sounds and pitches in both ears. You will also be asked to repeat a series of words to evaluate what is known as your speech perception. The results are then reviewed and, when needed, referrals are made to an ear, nose, and throat physician.

Ten Signs You Need a Hearing Test

1. You ask people to repeat themselves. Conversations feel like a struggle—both in person and on the phone.
2. You hear ringing in your ears. Known as tinnitus, these noises are described as a buzzing, roaring, clicking, or hissing in one or both ears. The sensation may come and go or occur all the time. You may also have episodes of dizziness or vertigo.
3. The volume is constantly turned up. You need to crank the TV to be able to hear dialogue or music comfortably, or you rely heavily on subtitles. Family and friends tell you the volume is “too loud.”
4. It sounds like everyone around you is mumbling. You are always telling people to speak more clearly. This is more noticeable in individuals with high-pitched voices.
5. Understanding speech in background noise is more difficult. Filtering out external sounds in a busy environment like a restaurant or a party is challenging.
6. You have trouble following multiple voices. While in a meeting or at the dinner table, it is difficult to differentiate who is talking and when. You frequently need to ask the people around you to take turns speaking.
7. You leave social situations feeling exhausted. You are straining just to hear. You feel fatigued and need to exert extra effort to hear at public events. Your body feels strained and your neck or back may feel tight from twisting and tensing.
8. Everyday sounds are missed. You do not hear the doorbell, alarm clock, or phone ringing. Your loved ones express concerns about safely carrying out everyday tasks.
9. You feel isolated or depressed. A strain has developed on your relationships with family and friends. You feel as though they are frustrated with you. It feels easier to avoid social gatherings or situations where there is a lot of noise.
10. Family members keep telling you that you need a hearing test. Many people with hearing loss do not realize they are missing out on sounds or conversation. The people who live with you or interact with you every day are your best resource. Listen to their advice.

Advancements in Hearing Aids

More than 28 million adults in the U.S. could benefit from hearing aids. However, less than one in three adults, age 70 or older, wear them. There is still a misconception that hearing aids are bulky, squeaky, and cause sound to be distorted. However, hearing aid technology has improved dramatically over the past two decades and continues to advance every year.

A wide variety of hearing aid styles, ranging from invisible to larger behind-the-ear devices, are available today. Most hearing aids are capable of connecting to Bluetooth, have rechargeable batteries, and can work in tandem with each other to provide the best sound in any given environment. Many have different settings that you can control with a smartphone. For example, if you are in a noisy restaurant, you can choose a program that suppresses background noise.

“Hearing aids can dramatically improve the quality of life for people with hearing loss,” says Dr. Nagler. “It is worthwhile to get a baseline exam, especially if you or your loved ones are noticing any hearing difficulty in your daily life.”

To make an appointment with Dr. Nagler, call 212-241-9410 or email ENTpatientservices@mountsinai.org.

Visual impairment is a common condition that affects more than 12 million adults over age 40 in the United States. But low vision—a condition that affects one in six adults throughout the nation—is different. People with low vision have reduced visual acuity (the common clinical measure of eye function) that cannot be corrected by standard glasses, contacts, medication, or surgery.

Leannza Tang, OD, an optometrist and Director of Low Vision Services at New York Eye and Ear Infirmary of Mount Sinai, explains low vision rehabilitation and what patients can do to seek care.

What causes low vision? What are the symptoms?

Low vision can be caused by many different eye conditions. Some of the more common include glaucoma, macular degeneration, and diabetic retinopathy, but there are other  conditions that can lead to vision loss as well.

The most common symptom is blurry vision that cannot be corrected or improved with standard eyeglasses, contact lenses, or eye surgeries. This usually translates to difficulty seeing small print. Patients may have difficulty reading a book; seeing a sign from a distance that they used to be able to; or even watching television.

Some people have distorted or missing spots in their central vision. This might make seeing people’s faces a lot more difficult. Other times, patients report side vision loss, which is what we typically see in glaucoma patients. When someone has severe side vision loss, this can affect their mobility.  Walking around as well as navigating stairs and curbs can be very difficult. These patients are prone to bump or trip over things.

Leannza Tang, OD

Are all low vision patients considered legally blind?

This is a common misconception about low vision patients that may not be true. Legal blindness is defined as someone with a visual acuity of 20/200 or poorer and/or has a visual field of no more than 20 degrees in their better seeing eye. Therefore, not all low vision patients are considered legally blind.

Eye care providers can clarify if you meet the criteria for legal blindness during your eye exam.

What is the difference between a low vision exam and a routine eye exam?

My low vision exams can be very different from a routine eye exam. One of the first things I tell patients is that I’m focused more on how they’re functioning day-to-day. Typically, the results of different scans, side vision tests, eye pressure tests, and dilations are all being managed by their ophthalmologist or optometrist so therefore, it is still very important to follow up with them as instructed.

I am interested in finding out what the patient’s goals or complaints are in relation to their vision. Are they having difficulty reading small print? Are the issues apparent when looking at price and medication labels or when reading a book and watching television? Do they have problems seeing street signs or bus numbers? The list goes on. I typically meet with patients for about one hour in which we discuss how to manage the condition and what devices might make navigating day-to-day life easier.

How do I manage low vision? Will the condition get worse?

I recommend seeing a low vision specialist. Many people think that you need to wait until you have severe vision loss before seeing a specialist but that is not true. Low vision physicians see a range of patients, from profound to more mild vision loss.

Low vision specialists can discuss any additional services that may benefit a patient. This includes orientation and mobility training for those who are having difficulty walking around or traveling independently because of their vision loss. There is training for household tasks like cooking, doing laundry, housework, and so on. There is also training to more efficiently use your personal devices including computers, smartphones, and laptops. If patients already have these devices, a specialist can teach them how to use built in accessibility and other features that might benefit them.

I also show low vision devices to see if they’re suitable to help a patient with their day-to-day tasks. This includes:

• A hand magnifier is probably the most common and familiar low vision device. Hand magnifiers make text bigger and are mostly for spot reading tasks like reading price labels or medication labels. Stand magnifiers are best for if you want to sit down and read a book for an extended period of time. To use it, you slide the device over your reading material while sitting at a desk or table. They come in different magnification powers, so I recommend a low vision evaluation to make sure that you are using the most appropriate device and power.
• Digital magnifiers operate very similar to stand magnifiers. These magnifiers allow you to adjust how big you want the words to appear as well as the color of the text for ease of viewing and reading.
• If patients are having issues seeing objects at a distance, like bus numbers or street signs, we can prescribe telescopes. We can do in-office training so that patients are able to use the device efficiently and comfortably.

It is very difficult to say whether someone’s vision will or will not get worse over time. It really depends on the person’s underlying condition that is causing their low vision. I will stress that it is important to follow up with the provider who is managing your eye condition and continue to take your prescribed medications and eye drops as instructed.

What resources are available for people with low vision?

Dealing with vision loss, whether sudden or gradual, can be very difficult. Some patients express feelings of sadness, frustration or anxiousness. A referral for behavioral health resources can be made to ensure a patient has the support they need.

Mount Sinai has excellent low vision resources. To learn more about low vision services at New York Eye and Ear Infirmary of Mount Sinai, please speak to your eye care provider or visit our website.