ENHANCING HEALTH AND WELLBEING ACROSS POPULATIONS:

INTRODUCTION:

The purpose of this essay is to identify a public health issue related in my field. To facilitate the discussion smoking as a public health issue has been chosen. The holistic impact smoking have on the wellbeing of an individual will be explored. The stage of change model and the Healthy Lives (2010) policy will be explored in relation to smoking.

The rationale for choosing this topic is because smoking is an important public health issue. The smoke is very toxic to every human tissue it touches on its way into, through and out of the smoker’s body (Ewles 2005). The impact of tobacco smoking on public health extends beyond the direct effects on the individual smoker and their personal health, plus taking into account the effect on their economic, environmental and social effects (Ewles 2005). Smoking harms nearly every organ of the body thereby causing many diseases, reducing quality of life and life expectancy. Also it has been estimated that in England, 364,000 patients are admitted to NHS hospitals each year due to smoking related diseases which translates into about 7,000 hospital admission per week and 1,000 admissions per day (ASH 2006). In the UK, smoking causes about a fifth of all deaths, approximately 114,000 each year, most of which are premature with an average of 21 years early (Ewles 2005). According to Peto et. al. (2003) cited in Ewles (2005), most premature deaths caused by smoking are Lung and coronary cancer, chronic obstructive heart diseases and coronary heart diseases with 42800, 29100 and 30600 deaths respectively every year. In addition, smoking is known to also bring increased risk of many debilitating conditions like impotence, infertility, gum disease, asthma and psoriasis (Ewles 2005). Research has also shown that non-smokers are put at risk by exposure to other people’s smoke which is known as passive or involuntary smoking and is also referred to as second-hand smoke (SHS) or environmental tobacco smoke (ETS) (Cancer Research 2009).

Smoking is considered as a health hazard because Tobacco smoke contains nicotine, a poisonous alkaloid, and other harmful substances such as carbon monoxide, acrolein, ammonia and tars.Gorvenment initiatives like the Public Health White Paper, choosing health; Making Choices Easier (DH 2004) will be addressed. The nurse’s role and other professions involved will be highlighted .Confidentiality shall be maintained throughout this essay as prescribed by the Nursing and Midwifery Council (2008).

In addition the fact about Nicotine (2006) suggests some people they smoke for different reason to justify their bad habits, some beliefs that smoking will make them loose weight/or maintaining their weight, peer pressure, reliefs stress, their families and siblings are smoking. Many people thinks it is a good thing to smoke whereas young ones thinks it is cool to be a smoker .The more you smoker too many cigarettes that’s how you get more the hormones from it.Smoking can cause chronic swelling of the mucus membranes of the airways, which adds to airways resistance.

Public health is defined it as the science and art of protecting and promoting health and wellbeing, preventing ill health and prolonging life through the organised effects of society (Faculty of Public Health 2010).

Smoking is defined as the inhaling and exhaling of smoke from tobacco of other drugs (World Health Organisation 2008). The Department of Health (2011) states that in the United Kingdom, smoking is one of the causes of avoidable premature deaths. The WHO (2008) estimates that tobacco smoking accounts for almost 6 million deaths worldwide that is including second-hand smoke and the number is expected rise to 7 million by 2020. Allender, et al (2009) states that for every smoking related death, 20 people are likely to suffer some disease associated with smoking such as cancer, COPD heart disease and stroke. In England between 2010-2011 smoking related diseases accounted for 5 percent of NHS hospital admissions and treating smoking related diseases costs the NHS approximately £5 billion a year (Ericksen et al 2012).

Smoking is known to affect the bio-psychosocial life of an individual as people smoke for different reasons Health Psychology: Biological, Psychological, and Sociocultural Perspectives. According to the DH (2009) nicotine, tar and bupropion are the most common toxins that have damaging effects to the body. “Pearson Nurse’s Drug (2010), states that Nicotine acts as a stimulant within the cardiovascular system and causes vasoconstriction, the thinning of blood vessels causing hypertension and chest pains.

Goddard (2008) suggests that tar, is also toxic when inhaled during smoking and it reduces the elasticity of the lungs thereby reducing the intake of oxygen in the blood stream.

Marmot The review key massage is on decreasing the social sectors and public groups has to work in organisation. (Marmot 2010) gradient in order to accomplish purposes in reducing health inequalities.

Chances to decrease the social gradient has to be universal that is starting at a local level. For example authorising local groups and individuals shall be effective than concentrating on the disadvantaged only. This means that the NHS, private.

The governments document Choosing Health (2004) seeks that people have choices about their health through health guides, receiving advice on their healthy living and being encouraged to make healthier changes in their lives. The introduction of the stop smoking service and a 24 hour free telephone service are important in supporting people to stop smoking. NICE (2011) highlights that Health professionals play a very important role in teaching them about the results of chain smoking and motivating them and empowering them into changing their behavioural life style.

Tanahill model describes three aspects of health promotion, these three circle Identify the major functions of public health. The aspects are Health Education, Prevention and Health Protection. A vital component of health promotion is health education which aims to change behaviour by providing people with the knowledge and skills they require to make healthier decisions and enable them to fulfill their potential FILL IN SOMETHING LEFT……

The health issues described above could be tackled in diverse angles. A Tanahill model of health is a guideline that professionals uses to protect, promote and educate individuals to make healthy choices. By educating and offering support health professionals can empower individuals to choice a healthy lifestyle. In 2012Hisocock, Bauld, Amos Filder and Munafo indicated that individuals use smoking as a coping device to manage pressures and stress. Also, Mendelsohn (2012) stated that smoking is intensely connected with depression, people that are depressed are more likely to smoke. In 2012, Turrell, Hewwitt and Miller identified that individuals that lives in deprived neighbourhood have more probability to smoke.

Health inequalities are the differences in health status or in the distribution of health determinants between different population groups. (RNC, 2012). These differences are social determinants and may include: housing, financial security, education and environment in which people are born, grow up and live in.

Housing: The National Institute for Health and Clinical Excellence (NICE) identified that the possibility of being a smoker is considerably intensified for individuals that lives in a rented accommodation.Moreover,In 2011,Howden –chapman,Chandola,Stafford and Marmot stated that the self-esteem of an individual can be affected by the quality of their house. They further stated that, the effect of stress and not having control over repairs of one’s house can affect mental health. Also 2012 study by Ansell,Gu,Tuiut and Shinha stated that increasing stress is connected with increase chance of smoking. In 2013, Prochorskaite and Miliene stated that, damp condition in the house can lead to breathing problems and asthma, skin irritation’s and are also related to poor housing.

According to Dahlgren and Whitehead (1991) Unemployment is a very popular determinant of health, many people and their family suffer from premature deaths because of this. NHS (2004) states that when an individual loses their job this can affect their self-esteem including their financial circumstances, which can therefore trigger emotional distress. Even though the relationship between unemployment and ill health is similar, unemployment is clearly related with greater levels of physical and psychological health for the individual who is unemployed, together with those close to them, as well as their community. NHS (2009). “A lot of jobless people will eventually lose contact with who they are as well as what they are” NHS (2012).

Tanahill model states that nurses should be role model when providing education or assistance about smoking, as Carmel and Rijid (2000) said that nurses were the best people to give information in educating and counselling the public about smoking. Bethel J (2008) impulses all health profession who have yet to quit smoking not to give patients confusing smoke motions. When counselling the Nurses should continuously use four A’s, Ask, Assist, Arrange and Advice. The individual would be asked about their smoking pattern and assisted in making a choice. The clever methodology should be applied in setting accurate aims for the patients to follow.

Information on the benefits of quitting to smoke and information such as brochures must be given to support the patient in making a choice People should be discharged and then referred to local NHS Stop Smoking . When discharging patients as nurse we should be helping by educating patients, counselling them, giving out flyers, try to educate them as much as we can, also nurses must make some referrals to community campaigners like Stoptober. Also knowledge of a person’s health beliefs is a condition to supporting interactive adjustment cessations.

Marmot Report (2010), showed that there is more possibility for adults who take parts in courses in education to give up smoking and also that adults learning significantly aid positive alterations in health behaviours.

The Report goes on to say individuals can be empowered through early intervention and local health trainers to manage their health however, several deprived individuals finds it hard to access and explore healthcare.

In 2012 Tenn , Herman and Wendling stated that, education may raise alertness of the damaging health effect of smoking and individuals that are more educated are far less expected to smoke.

As nurses we must indicate by models, we need to implement current smoking cessation interventions to reduce the tobacco credited flexibility and death.Smokers should be advised to stop smoking by following smoking cessations like clinical for behavioural supports.The National Institute for Health and Care Excecllence (NICE) recommending to reduce the prevalence of smoking in people in groups and ethnic groups. The Government gets profits by selling tobacco, yet this is an obstacle to people who are trying to stop smoking. When it comes to preventing and treating tobacco requirement nurses are the best people to act as agents of changes. Patients must have more counselling from Health professionals in order for them to quit smoking. Providing service users with some advices it benefits them to urges smoke, especially when speaking to somebody, keeping themselves busy or taking a walk. Smouldering cessations is a preventative health measure’s, yet several medical doctor give it only perfunctory mention during unchanging office appointments or avoid over it totally. (NRT) Nicotine Replacement Therapy or bupropion is to be given to people who are planning to quit smoking.These should be used as interventions.Goddard (2008) stated that smoking causes cardiovascular diseases occurs to people who are light smokers as well ( Dunn et al 1999). 24 300 deaths were from Chronic obstructive pulmonary disease such as chronic bronchitis and Emphysema were direct results of smoking.

According to Jerome (1987) smoking one cigarette immediately raises a person’s blood pressure and heart rate decrease the blood flow to the body extremities such as the fingers and toes. Brain and nervous system activity is stimulated for a short time and then reduced, a smoker may also experience dizziness, nausea, watery eyes and acid stomach.Apettite and smell are weakened.

Healthy Lives Healthy People (2010) highlight the vital role nurses play in the delivery of health promotion with particular attention on prevention at primary and secondary levels.Nurses have a wealth of skills and knowledge and use this knowledge to empower people to make lifestyle changes and choices. This encourages people to take charge of their own health and to increase feelings of personal autonomy (Karen.et.al 1999). Smoking is one of the biggest threats to public health, therefore nurses are in a prime position to help people to quit by offering encouragement, provide information and refer to smoking cessation services. Secondary prevention detects on early stage and it gives a swift treatment of diseases to cure the disease earlier.

This helps to reduce the impact on peoples in community also states that screening for diseases has to be done, such as computerized test so that it will detect the heart diseases early, eye tests for glaucoma, blood tests, Pap test for cervical test and Prostate Specific Antigen (APS) test for prostate cancer screening will benefit people by getting disease to be detected early so that the treatment can be initiated.Tannahil model states that preventing helps to lessens mortality, morbidity and all those serious complications.

In 2010 the white paper Healthy Live Healthy People set out the government long term policy for improving public health and in 2011 a new tobacco control plan was published (Department of Health 2011). The Whitepaper Healthy Life Healthy People set out a range of measures aimed at preventing people from starting to smoke and helping them to stop, such as banning cigarettes advertising on billboards, in size and action on tobacco intensified (DH, 2011).Issues highlighted were to ban retailers who sell tobacco to people.

England shops under a series of measures set out by the Department of Health (DPH 2011).In 2010 a box of cigarette was higher up by 15p, later the head of government increased duties by 1% above deflation. Liability will double to 2% above deflation over 2011-2015.NHS smoking services is the health promotion strategy, which was started by the government in 2000.The administration has made stop smoking aid presented on NHS treatment, bupropion (zyban).NICE has hand out regulation on use of NRT and bupropion (zyban).NICE has given control on use of NRT and bupropion and role of therapy and support. The government release money every year to encourage the stop smoking packages and training is given to health care workers and Nurses.

The Legal age limit was elevated from 16 to 18 years in October 2007 (ONS 2007 ).The Health Commission was to observed what PCT were doing to decrease smoking. Free smoking was banned from the 1

^st

of July 2007 in England and it’s now a crime /offence .National Health Services (NHS 2010) The NHS stop smoking services and A24 hour free phone services is offered to help broad public quit smoking. The DH has employed so many adverts in the broadcasting concerning the hazards of smoking. Additional amount planned in the 2010 White Paper -smoking kills was to end the advertising and sponsorship and promotion of tobacco (ONS 2007).

Who defines about what influences people’s health and what are effective interventions or strategies to improve health. Health promotion a process of enabling people to increase control over and to improve, their health. It implies that the ideology

moves beyond a focus on individual behavior towards a wide range of social and environmental interventions. Naidoo and Wills (2010), states ‘health promotion is based on theories

.

The Government strategy in England was to reduce the impact of tobacco in communities, campaigns organizations was organized and came up with a consultation report on the future of tobacco control (2008).this was to be achieved by working in partnership with local regional, national and international levels. In consultation 17% in the general population of which 23% among R&M to be achieved by 2015.Maybe fewer smoking people by 2020, and to achieve one in 20 fewer smoking people by 2030.The government‘s goals were to achieve by Better enforcement of existing laws with respect of underage smoking linking with social market campaigns and tackling underage smoking linking with social markets campaigns, also PTC authorities to work in partnership to set priority groups. The United Kingdom Support International initiative and effort on tobacco control through the world health organization. (WHO) treaty Framework Convention on tobacco (FCTC), (DOH 2008).As smoking remains to be a major cause of preventable premature deaths with statistics of 137,000 smokers approximately. North Staffordshire came up with a vision of tobacco control Agenda for West Midlands in 2005-2008 , with the aim of Support for smoking cessation:- this consist a network scheme providing support to people who are determined to stop. Professionals are always available to help with brief interventions. Reducing exposure to second-hand smoke:-businesses in Staffordshire are encouraged to implement smoke-free policies to reduce passive smoking therefore enhance a safe environment for the public children inclusive (Stoke-on-Trent PCT).Naidoo & Willis (2006) stated that reducing tobacco advertising and promotion:-this reduces smoke recruitment in youth.(smoke busters) (Stoke-on-Trent PCT National smoking communication.:- a national network and partnership in promoting smoke free environment in Staffordshire. Reducing availability of illicit and smuggled tobacco and underage sales.(DH2005).

The impact of tobacco smoking on public health extends beyond the direct effects on the individual smoker and their personal health, plus taking into account the effect on their economic, environmental and social effects (Ewles 2005).). Smoking harms nearly every organ of the body thereby causing many diseases, reducing quality of life and life expectancy. Also it has been estimated that in England, 364,000 patients are admitted to NHS hospitals each year due to smoking related diseases which translates into about 7,000 hospital admission per week and 1,000 admissions per day (ASH 2006). In the UK, smoking causes about a fifth of all deaths, approximately 114,000 each year, most of which are premature with an average of 21 years early (Ewles 2005). According to Peto et. al. (2003) cited in Ewles (2005), most premature deaths caused by smoking are Lung and coronary cancer, chronic obstructive heart diseases and coronary heart diseases with 42800, 29100 and 30600 deaths respectively every year. In addition, smoking is known to also bring increased risk of many debilitating conditions like impotence, infertility, gum disease, asthma and psoriasis (Ewles 2005). Research has also shown that non-smokers are put at risk by exposure to other people’s smoke which is known as passive or involuntary smoking and is also referred to as second-hand smoke (SHS) or environmental tobacco smoke (ETS) (Cancer Research 2009).

Having mentioned prons and cons of smoking .The writers ‘s opinion is that stopping smoking is a better idea.

Phenotypes

MS is most prevalent in young adulthood, with a higher percentage of females than males diagnosed, most commonly between the ages of 20-40 years (Garg and Smith, 2015). There are four clinical types of MS; relapse remitting MS (RRMS), secondary progressive MS (SPMS), primary progressive MS (PPMS), and progressive relapsing MS (PRMS).

These different clinical types are important for prognosis of disease and treatment pathway for each patient. RRMS, classified as discrete attacks occurring over a few days followed by periods of recovery with no attacks, is the most common clinical type found in 87% of patients (Loma and Heyman, 2011). No decline neurological function is shown during recovery periods.

During RRMS, lesions are formed in the central nervous system (CNS) by activated immune cells, and inflammatory attacks on the myelin and nerve fibres occur. Most patients progress gradually from RRMS to SPMS after a period of recurring relapses and gradual neurological deterioration as an effect.

PPMS is seen only in around 10% of patients, classified as progressive accumulation of disability from onset with no or minor relapses. There is a large effect on nerves of the spinal cord and fever brain lesions (Gholamzad et al., 2018). Less commonly, around 15% of patients skip straight from RRMS to PRMS stage, expressing a fast decline of disability from onset with clear relapses with or without full recovery (Ghasemi et al., 2017). PPMS and PRMS can only be distinguished at later stages when relapses occur.

With no single diagnostic test for MS, diagnosis of disease is based on symptoms and clinical presentation. More recently neuroimaging, a form of brain imaging used to image the structure and function of the nervous system, and cerebrospinal fluid (CSF) analysis, a group of tests used to evaluate the substances in the CSF are used to help diagnosis. CSF analysis looks for oligoclonal bands, IgG index and inflammatory markers (Garg and Smith, 2015). Abnormalilities in CSF include positive oligoclonal bands and inflammatory markers, found present in 85% patients with MS (Garg and Smith, 2015).

Symptoms

MS patients may express a broad range of symptoms over the course of their disease and lifetime, resulting from the involvement of sensory, motor, visual and brainstem pathways in the course of disease.

The extent of tissue damage and location of the lesion in the CNS express different symptoms ranging in severity and location in the clinical types of MS. The most common symptom, found in 90% of patients if clinically isolated syndrome (CIS) (Tullman, 2013). CIS is the first episode of neurological symptoms shown by a patient, usually lasting 24 hours or more.

An episode of damage is either monofocal, which expresses symptoms at a single site of the CNS, or multifocal, resulting in a wide range of symptoms across multiple sites (Tullman, 2013). Monofocal damage includes optic neuritis and other direct problems of the eye, whereas multifocal expresses broad symptoms including dizziness and numbness.

Symptoms range from primarily changes in vision (diplopia, blurred, pain), walking difficulties (due to weakness fatigue), to more severe and disabling symptoms including intestinal and urinary system dysfunction (constipation and bladder dysfunction), cognitive and emotional impairment (inability to learn and depression), dizziness and sexual problems (Ghasemi et al., 2017).

The harsh associated symptoms of sexual, intestinal and urinary symptom dysfunction are shown in 5% of patients, most commonly from PRMS category (Ghasemi et al., 2017). Without treatments these symptoms can cause unalterable and tough alterations to a patient’s everyday lifestyle.

Causes/Influencing factors/Aetiology

The aetiology of MS is thought to be caused by immune dysregulation triggered by genetic and environmental factors. Although MS is not defined as an inherited disease, there is evidence of strong genetic components to the aetiology shown by family aggregation and clustering. The low risk of 2-5% for developing MS in the general population increases by 10-50 times in first degree relatives of patients (Garg and Smith, 2015). There is also a high concordance rate in monozygotic twins of 1/3 (Garg and Smith, 2015). Several gene loci have also been expressed as risk factors, with the major histocompatibility complex (MHC) human leukocyte antigen (HLA).

The definite role of genetic factors remains undefined, with a larger emphasis on environmental factors which show more direct links to risks of developing the disease. There are multiple environmental factors linked to MS.

The Epstein Barr Virus (EBV) is a speculative risk factor, the link starting on the basis that both MS and infectious mononucleosis (an infection caused by EBV) occur roughly at the same age and coincide geographically. The risk of developing MS is approximately 15-fold higher in individuals with a history of EBV in childhood, and 30-fold higher in individuals infected with EBV in later life (Garg and Smith, 2015).  Although EBV seropositivity is seen frequently in MS, patients can also be seronegative, concluding EBV to be a strong risk factor but not a direct cause (Tselis, 2012).

The active form of vitamin D, 1,25 di-hydroxyvitamin D (2,25(OH)

₂

D), has effects on gene expression at the nuclear level, as well as a wide range of effects in the human body (O’Gorman et al., 2012). Observational epidemiological studies have shown beneficial roles of vitamin D in MS. A study by Munger in 2004 examined dietary vitamin D intake directly in relation to risk of MS in two large cohorts of women (Munger et al., 2004). The results showed a correlation of low vitamin D intake with increased risk of developing MS, with 173 cases with onset symptoms confirmed in follow ups (Munger et al., 2004).

The geographical location of countries across the world has shown a trend of increasing prevalence of MS with increasing latitude north and south of the equator. Latitude effects are thought to be related to decreasing gradients of sunlight and therefore decreased production of vitamin D. Geographical location is also dependant on lifestyle changes, diet and life expectancy. Dietary sources of vitamin D such as oily fish may compensate the lack of UV exposure.

More recently, lifestyle factors such as smoking have emerged as associated risks for MS. Cigarette smoke contains many unidentified components, some known effects of these substances include pro-inflammatory actions, direct tissue damage and increased apoptosis and anti-oestrogen effects (O’Gorman et al., 2012). The smoke also acts on the cellular and humoral components of the immune system, which can cause immunosupression and inhibitory effects, causing damage and therefore vulnerability to a person’s immune system. (O’Gorman et al., 2012). Smoking is viewed as general lifestyle risk with important but modest implications with MS and other autoimmune disorders.

Treatments

There is currently no cure for MS, with treatments designed to suppress symptoms and prevent progression of disease by targeting inflammation and immune activation.

Corticosteroids are the preliminary treatment, used to shorten duration of relapses and accelerate recovery for acute exacerbations. These steroids have anti-inflammatory effects, and are associated with immunomodulation, reduction of cerebral edema, and restoration of the blood brain barrier (BBB) (Loma and Heyman, 2011). Methylprednisolone is the commonly prescribed corticosteroid, with a course of  500 to 1000 mg/day for 3 to 10 days recommended for patients suffering acute attacks (Calabresi, 2004). Corticosteroids however do not alter the long-term course of MS or improve the overall degree of recovery.

Disease modifying treatments (DMT’s) aim to reduce frequency of relapses and number of lesions, slowing disability progression and therefore help to alleviate symptoms. DMT’s are used in all phases of the disease, however have shown most success for patients with RRMS and CIS (Garg and Smith, 2015). Currently there are 8 self-ijnected medications, 4 infused medications and 3 oral mediacations FDA approved as DMT treatments for MS (Garry et al., 2018).

Self-injected DMT’s include Beta Interferons and Glatiramer Acetate. Beta Interferons were first approved by the FDA for MS treatment in 1993 (Ghasemi et al., 2017).

Interferon beta-1a (Avonex, Plegridy, Refib) is a once weekly intramuscular interferon, whereas Interferon beta-1b (Betaseron, Extavia) is a subcutaneous interferon injected 3 times a week during treatment (Calabresi, 2004).

These naturally occurring cytokines account for therapeutic effects through their variety of immunomodulation and antiviral activities.

In multiple randomised, double-blind placebo-controlled trials conducted by  Li and Paty, the use of beta interferons resulted in a 50 to 80 percent reduction in inflammatory lesions visualised on brain MRI scans (Li and Paty, 1999) (Paty and Li, 1993).

Common side effects of beta interferons include flu-like symptoms and injection site reactions, with less common effects of thyroid abnormalities, liver enzyme elevation, depression, and leukopenia or anaemia (Garg and Smith, 2015).

Glatiramer Acetate (GA) is a synthetic complex of 4 amino acids that mimics myelin basic protein (MBP), using structural similarity of MBP to block the formation of myelin reactive T cells, and produce GA-specific regulatory T-cell expression and Th2 anti-inflammatory cytokines (Garg and Smith, 2015).

This alteration of T cell differentiation and production of Th2 cells with inflammatory properties helps to slow brain atrophy and protect the brain from axonal damage (Gholamzad et al., 2018). GA’s are well tolerated with common symptoms limited to mild pain and itching from injection site reactions (Gholamzad et al., 2018).

Infused medications consist of monoclonal antibodies (mAb), with different types differentiated by their structural similarity to the human antibody structure.

Monoclonal antibodies Alemtuzumab, Ocrelizumab and Natalizumab are used for MS treatment, with each mAb developed to bind to a specific target molecule (Garry et al., 2018). Natalizumab is a humanised mAb immunoglobulin (Ig)G4 antibody that targets CD49, 4 subunit of antigen-4 (VLA-4) receptor (Loma and Heyman, 2011). Binding of the (Ig)G4 antibody to CD49 prevents adhesion between the endothelial wall and the immune cell, blocking migration of leukocytes into the CNS (Loma and Heyman, 2011).

Side effects include headaches, fatigue, infections of urinary and respiratory tract. Cases of progressive multifocal leukoencephalopathy (PML) reactivation have also been reported  due to prolonged and severe immunosupression (Rommer et al., 2014). Ocrelizumab has shown good efficacy in clinical trials for RRMS patients, with ongoing phase III trials in PPMS (Rommer et al., 2014).

There are 3 oral therapies for MS treatment; Fingolimod, Teriflunomide and Di-methylfumarate. In comparison to injectable therapies, phase III studies have showed better or comparable effect on relapse rate reduction, MRI lesions and disability progression, with fewer and less severe side effects.

HSCT

Hematopoietic stem cell transplantation is the transplantation of multipotent stem cells, derived autologously from the patient’s own bone marrow or peripheral blood.