Ozonun tıpta kullanımı

PLEASE SCROLL DOWN FOR ARTICLE
This article was downloaded by: [TÜBTAK EKUAL]
On: 13 February 2009
Access details: Access Details: [subscription number 772815469]
Publisher Taylor & Francis
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House,
37-41 Mortimer Street, London W1T 3JH, UK
Ozone: Science & Engineering
Publication details, including instructions for authors and subscription information:
http://www.informaworld.com/smpp/title~content=t713610645
Ozone In Medicine
V. Bocci a; C. Aldinucci a; E. Borrelli b; F. Corradeschi a; A. Diadori c; G. Fanetti d; G. Valacchi a
a Institute of General Physiology, University of Siena, Siena b Institute ofThoracic and Cardiovascular Surgery,
c Department of Ophthalmology of the University of Siena, d Servizio Trasfusionale, Azienda Ospedaliera Senese, Siena, Italy
Online Publication Date: 01 January 2001
To cite this Article Bocci, V., Aldinucci, C., Borrelli, E., Corradeschi, F., Diadori, A., Fanetti, G. and Valacchi, G.(2001)'Ozone In Medicine',Ozone: Science & Engineering,23:3,207 — 217
To link to this Article: DOI: 10.1080/01919510108962004
URL: http://dx.doi.org/10.1080/01919510108962004

Full terms and conditions of use: http://www.informaworld.com/terms-and-conditions-of-access.pdf
This article may be used for research, teaching and private study purposes. Any substantial or
systematic reproduction, re-distribution, re-selling, loan or sub-licensing, systematic supply or
distribution in any form to anyone is expressly forbidden.
The publisher does not give any warranty express or implied or make any representation that the contents
will be complete or accurate or up to date. The accuracy of any instructions, formulae and drug doses
should be independently verified with primary sources. The publisher shall not be liable for any loss,
actions, claims, proceedings, demand or costs or damages whatsoever or howsoever caused arising directly
or indirectly in connection with or arising out of the use of this material.
OZONE SCIENCE & ENGINEERING 0191-9512101 53.00 + .OO
Vol. 23. pp. 207-217 lntcrnational Ozone Association
Rintcd in the U.S.A. Copright @ 2001
Ozone In Medicine
V.Bocci4, C.Aldinucci, E.Borrelli,' F.Corradeschi, ~ . ~ i a d o r iG' ,.F anetti3 and G.Valacchi
Institute of General Physiology, University of Siena, Via A. Moro, 53100 Siena, Tel: 0039 0577 234226;
Fax: 0039 0577 234219 ; email: Fisaen@unisi.it
'1 Institute of Thoracic and Cardiovascular Surgery
Department of Ophthalmology of the University of Siena
') Servizio Trasfusiodale, Azienda Ospedaliera Senese, Siena. Italy, Tel: 0039 577 585070, Fax: 0039 577 5861 67
') Corresponding author
Received for Review: 9 March 2000
Accepted for Publication: 6 December 2000
Abstract
Ozone therapy has been used as a complementary medical approach for half a century but it has
encountered skepticism by orthodox medicine because, particularly in the past, it has been used by
practitioners and others without a rational basis and appropriate controls. With the advent of modem
medical ozone generators incorporating a photometer, it has become possible to obtain precise ozone
concentrations and to evaluate some mechanisms of action and possible toxicity. In contrast with the
respiratory tract, human blood exposed to appropriate ozone concentrations is able to tame its strong
oxidant properties and neither acute, nor chronic side effects have ensued in millions of patients treated
with ozonated autohaemotherapy (0,-AHT). This review summarizes our studies aimed at clarifying
biological effects, defining any possible damage, the therapeutic window and suitable doses able to express
a therapeutic activity. A very interesting and promising aspect is the induction of the so-called heat stress
proteins (HSP) leading to adaptation to a chronic oxidative stress. The use of ozone in human therapy has
been reviewed but so far very few controlled clinical studies have been reported. Mostly on the basis of
anecdotal results, ozone therapy appears usehl in infectious diseases, immune depression, vascular
disorders, degenerative diseases and orthopedics.
Key Words
Ozone; Medical Applications; Reactive Oxygen Species; Antioxidants; Hemotherapy; Ozone Tolerance;
Introduction
Although ozone has been used as a potent
disinfectant since the first World War (I), its
validity in medicine still remains controversial, even
though the National Health Institutes of several
countries, namely Germany, Italy, Austria, Russia
and some of the United States now include ozone
therapy and bio-oxidative therapy among the
pharmacological approaches of complementary
medicine. In most of the United States, the problem
of ozone, as one of the worse pollutants in large
cities, has acquired such a preeminent consideration that
it practically denies its use in medicine. Studies in vitro
and in vivo (2-5), confirming its toxicity for the
respiratory tract have led to the co.nclusion that ozone is
"always" toxic for humans, animals and plants. The
authors believe that the generalization of this conclusion
is, at least in part, unjustified because ..we have
demonstrated that judicious use of ozone can be
therapeutically useful and atoxic (6-10). There is no
doubt that ozone is intrinsically toxic (1 I ) , but as any
other drug, when used properly, has a definite
therapeutic window. Moreover, every year millions of
207
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
208 V. Bocci et al.
patients all over the world undergo some sort of
ozone therapy and minimal, if any, side effects have
been noted. Some charlatans, mostly without any
medical qualifications, have caused a few deaths
because they inject directly the gas intravenously, a
procedure prohibited since 1986 in Europe (7;8; 10).
It is unfortunate that even today a few physicians
and many naturopaths and others, owing to the fact
that they cannot practice the classical hemotherapy,
predicate that intravenous injection of oxygen-ozone
is "the only effective way". This crucial problem
will be discussed in order to clarify the danger and
its basic irrationality.
The purpose of this brief review is four fold: firstly,
to present data from our Laboratory that show how
ozone, coming in contact with biological fluids,
decomposes and generates reactive oxygen species
(ROS), secondly, to define how ozone's messengers
can activate biochemical and immunological
mechanisms leading to biological effects, thirdly, to
show that we are now able to determine a
therapeutic window or, in other words, a range of
biologically active concentrations below which
ozone is practically inactive and above which can be
toxic. Fourthly, we will attempt to analyze the
results regarding therapeutic efficacy in five main
areas: infectious diseases, immune depression,
vascular disorders, degenerative diseases and
orthopedics. The breadth of ozone therapy, rather
than arising the suspicion of a "panacea", ought to
be envisaged as due to the multiform action of
ozone on cells with different functions.
The knowledge recently acquired allows one today
to plan rational clinical applications in different
diseases and to evaluate the therapeutic activity and
side effects. Future breakthroughs can be achieved
only if we are able to grasp firstly, the biological
activity of lipid oxidation products (LOPS),
secondly, the practical implications of the ozone
tolerance by clarifying the role of heat-stress
proteins (HSP) and, thirdly, if we will be able to
cany out randomized, double blind clinical trials
possibly performed in several medical centers.
The present paper intends to give a general
overview of the results so far achieved and therefore
technical details can be found in previous papers
(I 2- 15).
Ozone Mechanism
Progress in this field is expected only if we are able to
clarify precisely the mechanisms of action because it
will allow defining the therapeutic dose and possible
toxicity. We will examine separately the possible
mediators broadly defined as reactive oxygen species
(ROS) and the cell targets that are ultimately responsible
for the therapeutic response.
Ozone's active messengers
Both oxygen (about 97%) and ozone (no more than 3%)
dissolve in biological fluids according to their solubility,
relative concentrations, partial pressure and temperature
(1). However, there is a critical 'difference between these
two gases because oxygen is fairly stable in solution
while ozone decomposes immediately by avidly reacting
with polyunsatured fatty acids (PUFA) (1 1). This
implies that ozone does not obey Henry's law and
therefore an extremely dynamic equilibrium arises
between the ozone in the gas phase and the ozone
reacting and disappearing in the aqueous solution. Thus,
we can envisage a continuous flow of ozone into the
solution from the gas phase until the latter is exhausted.
It is felt that this crucial instability has not been fully
appreciated by cell biologists, who examine ozone
toxicity in tissue cultures maintained in a gas phase
where concentration of ozone, although very low (0.2 -
1 pprn), remains stable for several hours or days of
incubation. The final results are misleading because it is
obvious that overall cell toxicity cannot be simply
attributed to the low ozone concentration, but to the
uncalculated total sum of ozone that during every
millisecond has passed into the solution. In other words,
a cell layer in culture exposed to an ozone concentration
as low as 0.1 ppm may not be damaged if the exposure
lasts only ten min whereas total cell death may ensue
after 60 min exposure because ozone will continue to
dissolve during the following 50 min reaching the lethal
amount.
It has been shown (1 1) that the reaction between a mole
of an unsaturated fatty acid containing a cis-double bond
and 0, in water generates two moles of aldehyde and
one mole of hydrogen peroxide (H20,).
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
Ozone in Medicine 209
H20, is also generated when O, reacts with
physiological saline.
The reduction potential is smaller (0.682 volt) in the
semireaction towards H,02 than directly towards
H20 (1.229 volt). Indeed we have demonstrated (14)
that after ozonation of either saline or human
plasma, H,02 is formed in both liquids with the
important difference that H,O, in the plasma has a
very short half-life (about 2.5 min) due to the
presence of traces of enzymes such as glutathione
peroxidase (GSH-Px) and catalase, which are able to
degrade H202. Appropriate enzyme inhibitors are
able to prolong the lifetime of H20, while addition
of catalase, as it was expected, accelerates its decay
(14). The other important reaction is that 0,, by
reacting with PUFA, will generate a number of
LOPs such as hydroperoxides, isoprostanes,
platelet-activating factor (PAF) and terminal
products such as malondialdehyde and 4-
hydroxyponenal (HNE) (162 1 ) The latter
compound is becoming particularly interesting
because, depending upon its final concentration
(>lo ph4 or < I pM), may either be harmful or act
as a physiological messenger, respectively (22;23).
Owing to the wealth and heterogeneity of PUFA,
several types of LOPs may be generated and their
biological activities, including potential toxicity,
remain to be explored in vivo. Once again,.results
obtained in vitro by using apparently toxic LOPS
may not be applicable in vivo owing to their rapid
turnover and, as an example, enzymes such as
glutathione transferases and aldehyde
dehydrogenases are involved in the metabolism of
HNE (16). Phospholipases and sphyngomyelinase
are likely to be activated by LOPs and this may lead
to an amplification of some biological processes.
Furthermore LOPS have a short half-life but, upon
reinfusion of ozonated blood, may reach specific
sensors situated in critical organs such as bone
marrow, spleen, liver and other sectors of the
immune system. If this is true, .LOPS may be
responsible for transmitting the information of
peroxidative stress and possibly inducing the
upregulation of antioxidant enzymes, hence the
tolerance to 0,. This dubbed as
"oxidative stress adaptation" or oxidative
preconditioning (7;24-26) is extremely interesting
because it could allow a reversal of chronic
oxidative stress typical of degenerative diseases. We
have already demonstrated an increase of
antioxidant enzymes (7) and we are examining.
levels of heme oxygenase (HO) activity. The
isoform 1 of the latter enzyme (HO-I), also known as
heat shock protein 32 @sp 32), is inducible and is
responsible for the conversion of heme into biliverdin,
carbon monoxide (CO) and free iron (27-29). ,
Cytochrome P450 constitutes another source of heme
undergoing degradation via HO-1. We would like to
emphasize that the above products, until recently
regarded as toxic waste destined only for excretion, are
compounds with great physiological and a possible
therapeutical role: bilirubin (via biliverdin reductase) is
a crucial lipophylic antioxidant and CO may function as
a gaseous regulator of endothelial tone in synergy with
nitric oxide (NO). Indeed we have just demonstrated
that human endothelial cells exposed to ozonated
plasma increase the release of NO (30). Nitrosothiols
such as S-nitrosocysteine, S-nitrosoglutathione and Snitrosoalbumin,
formed in human plasma to buffer NO'S
concentration, have physiological significance because
function as a reservoir for NO (31). Another important
mechanism of activation that has been partly clarified
(13) is the opening of Ca2' channels somehow related to
ROS acting on the external part of the cell membrane
leading to a sudden increase of intracellular Cal'
concentration with consequent enzymic activation. So ,
far we have only indirect evidence of this phenomenon
by either chelating tjle extracellular Ca2+ with citrate
used as a blood anticoagulant or by adding from 5 up to
25 rnM Ca2+ in heparinized blood (13) but obviously it
will be important to measure the actual intracellular
increase of Ca2+
Effectors and the biochemical targets
It is now clear that ozone works indirectly in different
ways: owing to' the fact that H,O, is an unionized
molecule and its passage through the cell membrane is
free, its sudden increase in the extracellular water is
immediately transferred into the intracytoplasmic water,
but the intracellular environment counteracts this
potentially toxic increase by quenching it with reduced
glutathione (GSH) coupled to GSH peroxidase. This
causes an increase of oxidized glutathione (GSSG) and a
decrease of the GSWGSSG ratio, which is rapidly
reconstituted by the action of GSH reductase in turn
exploiting the NADPWNADP reservoir. Lowering the
NADPH level enhances the activity of glucose 6
phosphate dehydrogenase (G6PD) that, particularly in
the erythrocytes, leads to the activation of. the hexose
monophosphate shunt. When necessary an excessive
increase of intracytoplasmic Y,02 is also double
checked by catalase. There is a concomitant activation
of glycolysis with increased ATP and a still
controversial increase of 2-3 diphosphoglycerate (2-3
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
210 V. Bocci et al.
DPG) production as key enzymes involved in this
process have not yet been shown to be activated
(32;33). Obviously the shift to the right of the HbO,
dissociation curve would favor an increased oxygen
delivery to hypoxic tissues (7;lO). It has also been
claimed (34) that the erythrocytic membrane
becomes more fluid and more negatively charged,
that blood viscosity decreases due to
hypofibrinogenemia and to a decreased level of low
density lipoproteins (LDL). However Morgan et al.
(35) found that erythrocytes from ozone-exposed
mice exhibited decreased deformability and
therefore all of these claims must be controlled
because we must be sure if indeed ozone can
improve, blood rheology in ischemic diseases.
As far as the activation of cytokine synthesis in
leukocytes is concerned, it is now well accepted that
the sudden surge of intracytoplasmic H,O, is finally
responsible for the activation of the nuclear
transcription factor (NF-kl3). Briefly, H20,, by
activating specific protein kinases, would
phosphorylate the I-KB subunits that detach from
the NF-k8 complex. The free heterodimer (p50-p6S
proteins) can then move into the nucleus where,
after binding to DNA control elements, activates
gene expression and the successive synthesis of
interferons and interleukins as shown by us (12-
15;36) and others (37;38).
The transient rise of intracytoplasmic H,O, prompts
a few considerations: the first one is that the 0,
concentration must be adequate to allow a sufficient
H,O, generation for the activation of transducer
molecules and to counteract, the simultaneous
degradation, and the second is that H,02
concentration must reach a critical threshold. If it is
below the liminal value, activation will not occur
but if it is excessive, damage may result implying
the relevance of having identified the therapeutic
window between about 20 and 80 pglml of gas per
ml of blood. If the 0, concentration is below 20
pglml, 'most of the oxidant power of 0, will be
quenched by the natural antioxidants (between 1.28
and 1.83 mM plasma) (39) and therefore the
necessity of measuring precisely the 0,
concentration to avoid either a placebo or a toxic
effect is of crucial importance. On the experimental
basis of progressively increased hemolysis, ozone
concentrations higher than 80 pglml are more likely
detrimental than beneficial.
Little is known about the biological activity of LOP
such as hydroperoxides, isoprostanes, malondialdehyde
and 4-hydroxyalkenals produced during blood
ozonation. Aggregation of platelets, as we have
observed in platelet rich plasma anticoagulated with
heparin (40), is at least in part attributable to released
PAF (21). While some of these can act as physiological
messengers (18;20-23) they appear to be, particularly in
vitro, very toxic (17;22;23). Their production and
consequent plasma levels are somewhat related to the
ozone dose and it is conceivable that in vivo a low
ozone dose may express a more favorable
activityltoxicity ratio than a higher ozone dose. Thus,
once again, we should aim to define in different
pathologies the optimal dose that may be either in the
low (20-40 pg/ml per ml of blood), or in the mediumhigh
range (30-80 pglml per ml of blood).
Moreover LOPS may exert the overlooked and yet
crucial function for transmitting the information of on
ongoing peroxidative stress to distant organs with the
purpose of inducing the "oxidative stress adaptation" or
ozone tolerance (24-26;41-48). This can be achieved
only by slowly activating gene expression towards the
synthesis of heat-shock proteins, antioxidants enzymes
(GSH-Px, catalase, superoxide dismutases etc), DNA
repair enzymes and, most important, heme-oxygenase
(27-29). This may lead to increased bilirubin levels (49)
and local release of CO that, associated to increased
endothelial production of NO (30) may well explain the
vasodilation and consequent clinical improvement
observed in limb ischemia treated with 0, AHT. It is
almost needless to say that upregulating the production
of antioxidant enzymes in patients with degenerative
diseases (favored or caused by a life-long oxidative
stress) is the simplest way to readjust the redox balance,
possibly leading to a stabilization of the disease.
Administration of antioxidant compounds may be
helpful (50;Sl) but, most likely, not so effective for
neutralizing ROS as the intracellular increase of
antioxidant enzymes.
Applications of Ozone Therapy in Medicine
Today, a better understanding of the basic reactions of
ozone able to activate different biological functions
allows the dispelling of skepticism surrounding ozone
therapy. Although its application is extremely versatile
there are two important limitations: firstly, ozone should
never be inalated as the fluid film lining the tracheobronchial
mucosa is too thin to protect it from the .
oxidative insult (11) and secondly, the gas mixture of
OJO, should never be injected intravenously (IV) either
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
Ozone in Medicine 211
because it can cause oxygen embolism and because
no meaningful blood /ozone ratio can be ever
calculated. We will never get tired of repeating that
human organism, although composed of almost 66%
water should not be compared and treated as a water
sterilization plant. Were we to allow the IV gas
administration, it would cause severe side effects
and many deaths each year.
On the other hand the approach consisting in the
exposure of a precisely measurable volume of the
patient's blood (200-250 ml) to an equal volume of
gas (1 to l), of which the ozone concentration can
be accurately measured in real time by photomeby,
is by far the most scientific, simple, inexpensive and
side-effects free procedure. Most of the merit goes
to Wolff (52) who applied the ozonated
autohemoterapy (0,-AHT) in the late 70s. The
optimized procedure that must be can-ied out in
neutral glass and ozone-resistant tubing where the
inlet is separated from the outlet equipped with a
standard blood, filter has been recently described in
detail (53). Standard autotransfusion bags made of
polyvinyl chloride (PVC) additioned with about
40% additives have been banned by the Italian
Ministry of Health after our demonstration (53) that
ozone causes the release of significant amounts of
plastic microparticles and phthalates into the blood.
Other routes of administration of ozone can be
allowed for selected applications: the subcutaneous
(SC) route for treating lipodistrophy; the
intramuscular (LM) route into the paravertebral
muscles aAer locating the point(s) triggering low
back pain; the intradiscal- intraforaminal andfor the
epidural route for treating a herniated disc; the
intraarticular or periarticular route for treating acute
and chronic arthrosis. Knoch et al. (54), Carpendale
et al. (55) and ourselves (56) have evaluated pros
and cons of the rectal insufflation of 0,-0, as a
possible option when 0,-AHT cannot be used for
difficult venous access. This route has been used in
human. immunodeficiency virus (HIV) infection
( 5 9 , chronic hepatitis, ulcerative colitis and
Crohn's disease with apparently satisfactory results
(54) using up to 800 ml of 0,-0, at a maximal 0,
concentration of 40 pg/rnL administered within 5
minutes. In the case of chronic bacterial and
parasitic infections becoming resistant to antibiotics,
low 0, concentration (3-5 pg/mL) have been also
insufflated into the oral, nasal, tuba1 (during 30 sec
apnea), vaginal, urethral, vesical, pleural and
peritoneal cavities. Obviously the technique of gas
insufflation is a very empirical and approximate one but
it can be useful, as ozone does not allow bacterial
resistance.
Which are the diseases likely to benefit from the
application of ozone therapy? It appears reasonable and
ethical to use ozone especially when conventional
therapies are ineffective or not available as too often
occurs in poor countries. Obviously, by considering the
potent disinfectant action of 03, top priority goes to all
sorts of bacterial, viral and fungal infections. Either gas,
or ozonated water, or ozonated oil display a cleansing
and disinfectant effect (1 ;57-63).
Moreover 03-mT, combined with topic therapy, can be
helpful because, as previously ,discussed, it activates cell
metabolism and the immune system. Indeed various
immunodeficiencies associated with chronic viral
diseases and metastatic cancer, particularly after highintensity
chemotherapy, may benefit from a long cycle
(about 50 treatments, twice weekly for six months) of
0,-AHT that, in comparison to interferon, highly active
antiretroviral therapy (HAART) and cytostatics does not
procure acute or chronic side effect (64;65). Actually
the majority of patients reports an unusual feeling of
well-being that should not be neglected.
Unfortunately, for the time being, we have to rely on
anecdotal reports (65). One clinical study in HIV
infection (66) yielded doubtful results because blood
was badly mistreated by heat, W irradiation and 0, in
unknown concentration.
In western countries several circulatory disturbances
,bind-limb ischemia, heart-brain-retinal ischemia) due
to atherosclerosis, diabetes, smoking, aging and a too
intense lifetime oxidative damage represent a
formidable medical problem that cannot. be entirely
coped by orthodox medicine.
0,-AHT has shown therapeutic effects particularly in
patients refractory to conventional treatments because,
as it has been mentioned, expresses multiple actions
such as vasodilation, increased delivery of oxygen in
hypoxic tissues and release of wound healing factors
(67). Clinical results in acute cerebro-vascular disorders,
chronic ischemic cardiopathy and even in the 111--1V
stages of hind-limb ischemia have been remarkable,
particularly, when a systemic treatment was combined
with a topical one on torpid ulcers and incipient necrosis
(33; 68-70). Two randomized, placebo controlled (0,-
AHT) cross-over studies have been performed to
evaluate the efficacy of 0,-AHT in patients with age-
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
212 V. Bocci et al.
related macular degeneration (ARMD) (33) and
with mild hypertension (71). Significant clinical
improvement was achieved in both trials although it
faded 2-4 months after the end of the treatment.
However, as it happens with other medications, this
is to be expected and can be minimized by
continuing the treatment at a slow pace.
As far as degenerative diseases are concerned,
preliminary studies by using 0,-AHT and 0, rectal
insufflation cairied out in patients with cardiac
infarction (72), neurodegenerative disease (73) and
ARMD (33) have shown clinical improvement and
interestingly a progressive increase in GSH Px,
glucose-6-phosphate dehydrogenase and superoxide
dismutase in erythrocytes. However there is an
urgent need for programming controlled studies in
order to show that ozone therapy can induce a state
of oxidative stress adaptation, possibly capable of
stabilizing the disease.
Finally injections of small volumes of 0,-0, at a 0,
concentration below 30 'pg/ml ire being used in
orthopedic pathology, via peri, or intrarticular, or
intradiscal injection (74; 75). It appears that the
treatment that is occasionally painful for a few
minutes has no side effects and in about 70 % of
patients allows pain relief, decongestion,
reabsorption of edema and improved mobility (74;
75). How ozone works remains hypothetical: after
intradiscal injection, ozone generates hydrbxyl
radicals (OH') measured by electron spin resonance
(Bocci et al, manuscript in preparation) that can
degrade proteoglycans in the degenerate nucleus
pulposus leading to its reabsorption with consequent
reduction of herniated material responsible for
radicular pain. In the synovial membrane ozone
therapy may either induce the release of
immunosuppressive cytokines andlor
proinflammatory cytokine antagonists as well as the
over-expression of antioxidant enzymes able to
block excessive ROS formation. In regard to the
injection of 5-10 mL 0, -0, (15-20 pg/ml) into the
trigger points of paravertebral muscles
correspondent to the metamers of the hernial disc,
we have proposed (76) that the "chemical
acupuncture" due to the needle and ozone inhibits
amyelinic nociceptors fibers and activate the
antinociceptive system. This explanation appears
plausible because the successive analgesia permits
muscle relaxation and vasodilation with consequent
improvement of local muscular physiology and
disappearance of pain. Brayda-Bruno and Cinnella
(77) have reported that about 70 % of patients improve
after a few session of this easy, risk free procedure. It is
worth noting that lower back pain syndrome is very
common and it is advantageous to try this minimally
invasive treatment. However, as it was proposed in 1998
(76), it is impellent to compare this procedure against a
wait-list control, two placebo controls (one with 0,
alone and another without any gas) and a standardtreatment
control.
Conclusions and Perspective
On the basis of experimental results obtained in the last
decade (6;7;91;2 - 15;24-26;36-38;40), we have selected
a range from 20 up to 80 pg/ml of ozone per ml of blood
to be used for different pathologies, within which, no
damage to blood components has been noticed. An
orientative scheme of dosages has been previously
reported for different diseases (10) depending upon
whether the therapeutic activity is mainly exerted by
either erythrocytes or leukocytes (7; 8;10). In order to
avoid toxicity and allow oxidative stress adaptation, we
are applying the "start low, go slow" principle: that is
0,-AHT is performed starting with very low ozone
concentrations (20-25pg/mL per ml of blood) to be
increased in single steps of 5 pg/mL to the highest level
between 40 and 80 pglmL depending upon the disease
and the state of the patient (10).
Although we do not yet have unequivocal clinical data
based upon controlled double-blind studies, we have
encouraging evidence suggesting that ozone therapy can
be useful in vascular, infectious and degenerative
diseases (1;7;10;34;55;57-63;68-73). Whether ozone,
therapy can be useful in metastatic cancer (65) and
surprisingly in orthopedics (74-77), respiratory and
immune diseases remains to be seen and it should be
ascertained starting with cautious and controlled
experimentation.
Even if, theoretically, ozone therapy implies always an
oxidative insult, this must be carefully calculated on the
basis of a precise ozone dose and brief time of exposure.
Luckily this is possible owing to the large antioxidant
potential of blood (39;40;50;5 1). that is practically
impossible to overwhelm with the indicated ozone
concentrations. Moreover, during the course of therapy
the total antioxidant status must be sustained. by daily
administration of antioxidant vitamins (0.5 g of vit C, 10
mg vit E, Se, etc and at least 0.6 g of N-acetylcysteine as
a precursor of GSH) accompanied by a diet rich in fresh
vegetables and fruits.
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
Ozone in Medicine 213
The concept of "oxidative stress adaptation" must
be thoroughly evaluated because it is expected to
lead to great improvements. If this idea will prove to
be correct against all the most pessimistic views of
ozone as a therapeutic agent (ll), we will have
demonstrated that ozone is indeed a paradoxical
molecule and that prejudices are the worst foes of
biology and medicine. In order to achieve a suitable
and smooth adaptation, the best strategy seems to
start with low and slowly increasing ozone dosages.
Two to three weeks may be necessary before
measuring a substantial increase of antioxidant
enzymes in erythrocytes. One must also take into
account that erythrocytes have a fairly slow turnover
(78) and therefore it takes a few weeks before the
newly "super-gifted" erythrocytes, released from
the bone marrow, can progressively substitute the
old ones. Thus the application of the "start low, go
slow" principle (10) appears reasonable for
demonstrating the validity of the concept.
In conclusion, in spite of our efforts during the last
decade to give a solid scientific basis to ozone
therapy, much work remains to be done. Ozone
therapy is in the middle of a schizophrenic situation:
on one hand, if one reads the weekly reports in the
oxgists, one remains appalled by wonderful
therapeutic achievements obtained in most cases by
charlatans without any medical qualification. This is
very detrimental for the real progress of ozone
therapy as desperate patients searching a hopeful
treatment are not in the position to distinguish
between the truth and the fake. On the other hand, in
the age of molecular medicine and gene therapy,
ozone therapy appears at best as an obsolete,
empirical and still doubtful approach. It reminds the
well-hown Indian story about the blind men and
the elephant. We touch it, we smell it but we still do
not see it. However, as-it happens in Science, even
gene therapy that seemed so promising present great
problem (79). Against all the odds, I firmly believe
that if we can continue with an appropriate
biological and clinical experimentation, ozone can
become an important therapeutic agent because it
can reactivate a variety of biological hctions
crucial for regaining health and is very cheap, easy
to use, versatile and atoxic, if used properly.
Acknowledgements
This work was partly supported by MURST grants
(ex40%). The editorial assistance of Mrs. Helen Carter
and Patrizia Marrocchesi is gratefully acknowledged.
References
1. R.Viebahn, The use of ozone in medicine (Iffezheim:
ODREI Publishers, 1999), p.1-148.
2. M.G.Mustafa, "Biochemical basis of ozone toxicity",
Free Radic. Biol. Med. 9: 245-265 (1990).
3. . R.B.Devlin, W.F.McDonnel1, R.Mam, S.Becker,
D.E.House, DSchreinemachers, H.S.koren,
"Exposure of humans to ambient levels of ozone for
6.6. hours causes cellular and biochemical changes in
the lung", Arner. J. Respir. Cell Molec. Biol. 4: 72-8 1
(1991).
4. W.A.Pryor, "How far does ozone penetrate into the
pulmonary aidtissue boundary before it reacts?", Free
Radical Biol. Med. 3:83 -88( 1992).
5. W.H.M.Stevens, P.D.Conlon, P.M.O'Byme, "Ozoneinduced
oxygen radical release from bronchoalveolar
lavage cells and airway hyper-responsiveness in
dogs", J. Physiol. 486.1: 257-265 (1995).
6. V.Bocci, E.Luzzi, F.Corradeschi, L.Paulesu, "Studies
on the biological effects of ozone: 5. Evaluation of
immunological parameters and tolerability in normal
volunteers receiving ambulatory autohaemotherapy.",
Biotherapy 2: 83-90 (1994).
7. V.Bocci, "Ozone as a bioregulator. Pharmacology
and toxicology of ozone therapy today", J. Biol.
Regulat. Homeost. Agent. 10: 3 1-53 (1996).
8. V.Bocci, "Is ozone therapy therapeutic ?", Perspect.
Biol. Med. 42: 131-143 (1998).
9. V.Bocci, N.DI Paolo, G.Garosi, C.Aldinucci,
E.Borrelli, G.Valacchi, F.Cappelli, L.Gueni,
G.Gavioli, F.Corradeschi; R.Rossi, F.Gia~erini,
P.DI Sirnplicio, "Ozonation of blood during
extracorporeal circulation. I. Rationale, methodology
and preliminary studies", Int. J. Artif. Organs 22:
645-65 1 (1 999). .
10. V.Bocci, "Biological and clinical effects of ozone.
Has ozone therapy any future in medicine ?", Brit. J.
Biomed. Sci. 56: 270-279 (1999).
11. W.A.Pryor, "Mechanisms of radical formation from
reactions of ozone with target molecules in the lung",
Free Radical Biol. Med. 17: 45 1-465 (1994).
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
214 V. Bocci et al.
V.Bocci, E.Luzzi, F.Corradeschi, L.Paulesu,
R.Rossi, E.Cardaioli, P.DI Simplicia, "Studies
on the biological effects of ozone: 4. Cytokine
production and glutathione levels in human
erythrocytes.", J. Biol. Regulat. Homeost. Agent.
-7: 133-138 (1993).
V.Bocci, E.Luzzi, F.Corradeschi, L.Paulesu, .
A.DI Stefano, "Studies on the biological effects
of ozone: 3. An attempt to define conditions for
optimal induction of cytokines", Lyrnphokme
Cytokine Res. u: 121-126 (1993).
V.Bocci, G.Valacchi, F.Corradeschi,
C.Aldinucci, S.Silvestri, E.Paccagnini, R.Gerli,
"Studies on the biological effects of ozone: 7.
Generation of reactive oxygen species (ROS)
after exposure of human blood to ozone", J. Biol.
Regulat. Homeost. Agent. 12: 67-75 (1998).
V.Bocci, G.Valacchi, F.Corradeschi, G.Fanetti,
"Studies on the biological effects of ozone: 8.
Effects on the total antioxidant status and on
interleukin-8 production", Mediat. Inflamrn. 7:
313-317 (1998).
H.Esterbauer, R.J.Schaur, H.Zollner, "Chemistry
and biochemistry of 4-hydroxynonenal,
malonaldehyde and related aldehydes", Free
Radic. Biol. Med. 11: 81-128 (1991).
A.Del Corso, M.Dal Monte, P.G.Vilardo,
I.Cecconi, R.Moschini, S.Banditelli,
M.Cappiel10, L.Tsai, U.Mura, "Site-specific
inactivation of aldose reductase by 4-
hydroxynonenal", Arch. Biochem. Biophys. 350:
245-248 (1 998).
G.Leonarduzzi, A.Scavazza, F.Biasi,
E.Chicrpotto, S.Camandola, S.Vogl, R.Da~gel,
G.Poli, "The lipid peroxidation end product 4-
hydroxy-2,3-nonenal up-regulates transforming
growth factor pl expression in the macrophage
lineage: a link between oxidative injury and
fibrosclerosis", FASEB J. 1_L: 85 1-857 (1997).
J.D.Morrow, L.Jackson Roberts, "The
isoprostanes: unique bioactive products of lipid
peroxidation", Prog. Lipid Res. 36: 1-21 (1997).
C.N.Serhan, J.Z.Haeggstrom, C.C.Leslie, "Lipid
mediator networks in cell signaling: update and
impact of cytokines", FASEB J. 10: 1147- 1 158
(1996).
T.M.Mclntyre. G.A.Zirnrnerman. S.M.Prescott,
"Biologically active oxidized phospholipids", J.
Biol. Chem. 274: 25 189-25192 (1999).
M.U.Dianzani, "4-Hydroxynonenal and cell
signalling", Free Rad. Res. 2: 553-560 (1998).
M.Parola, G.Bellomo, G.Robino, G.Barrera,
M.U.Dianzani, "4-Hydroxynonenal as a biological
signal: molecular basis and pathophysiological
implications", Antiox. Redox Signal. 1: 255-284
(1999).
V.Bocci, "Does ozone therapy normalize the cellular
redox balance?", Med. Hypotheses 46: 150- 154
(1996).
E.Barber, S.Menindez, O.S.Le6n, M.O.Barber,
N.Merino, J.L.Calunga, E.Cruz, V.Bocci,
"Prevention of renal injury after induction of ozone
tolerance in rats submitted to warm ischaemia.",
Mediat. Inflarnrn. 8: 37-41 (1999).
O.S.Leon, S.MenCndez, N.Merino, R.Castil10, S.Sam,
L.PCrez, E.Cruz, V.Bocci, "Ozone oxidative
preconditioning: a protection against cellular damage
by free radicals", Mediat. Inflarnrn. Z: 289-294
(1998).
R.Galbraitb, "Heme oxygenase: who needs it?", Proc.
Soc. Exp. Biol. Med. 222: 299-305 (1999).
F.Amersi, R.Buelow, H.Kato, B.Ke, A.J.eoito,
X.D.Shen, D.Zhao, J.Zaky, J.Melinek, C.R.Lassman,
J.K.Kolls, J.Alam, T.Ritter, H.D.Volk, D.G.Fanner,
R.M.Ghobrial, R.W.Busuttil. J.W.Kupiec-Weglinski,
"Upregulation of heme oxygenase- 1 protects
genetically fat Zucker .rat livers from
ischernia/reperfusion injury", J. Clin. Invest 104:
1631-1639 (1999).
M.Suematsu, Y.Ishirnura, "The heme oxygenasecarbon
monoxide system: a regulator of hepatobiliary
hction", Hepatology 1:3- 6 (2000).
G.Valacchi, V.Bocci, "Biological effects of ozone on
human endothelial cells", Mediat. Inflamm. (2000).
In press.
A.R.Butler, F.W.Flitney, D.L.Williarns, "NO,
nitrosonium ions, nitroxide ions, nitrosothiols and
iron-nitrosyls in biology: a chemist's", Trends
Phamcol. Sci. 16: 18-22 (1995).
R.Viebahn-Hhsler, "Einfluss auf .den
erythrozytenstoffwechsel". In: Ozon-Handbuch.
Gnmdlagen. Priivention. Therapie (LandsbergILech:
Ecomed, 1999).
A.Diadori, V. Bocci, F. Carraro, A. Nuti, F.
Corradeschi, G. Ferrari, L. Sabatini, S. Silvestri, and
R. Frezzotti, "Ozone therapy and age related mcular
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
Ozone in Medicine 215
degeneration: a pilot study". In:
F.CECCHERELL1 and F. GIRON (Eds.),
L'Ozonoterapia nel 2000 (Torino: Edizioni
Libreria Cortina, 1999), pp.33-45.
O.Rokitansky, "Klinik und Bioche~e der
Ozontherapie.", Hospitalis 2: 643-647 (1982).
D.L.Morgan, A.F.Dorsey, D.B.Menze1,
"Erythrocytes from ozone-exposed mice exhibit
decreased deforrnability", Fundam. Appl.
Toxicol. 5: 137-143 (1985).
V.Bocci, L.Paulesu, "Studies on the biological
effects of ozone 1. Induction of interferon
gamma on human leucocytes", Haematologica
-75: 510-515 (1990).
K.Arsalane, P.Gosset, D.Vanhee, C.Voisin,
Q.Harnid, A.B.Tonne1, B.Wallaert, "Ozone
stimulates synthesis of inflammatory cytokines
by alveolar macrophages in vitro", Amer. J.
Respir. Cell Molec. Biol. 13: 60-68 (1995).
E.B.Haddad, M.Salmon, H.Koto, P.J.Bames,
I.Adcock, K.F.Chung, "Ozone induction of
cytokine-induced neutrophil chemoattractant
(CMC) and nuclear factor-kappa b in rat lung:
inhibition by corticosteroids", FEBS Len. 379:
265-268 (1996).
N.J.Miller, C.Rice-Evans, M.J.Davies,
V.Gopinathan, A.Milner, "A novel method for
measuring antioxidant capacity and its
application to monitoring the antioxidant status
in premature neonates", Clin. Sci. 84: 407-412
(1993).
V.Bocci, G.Valacchi, R.Rossi, ~'.~iustarini,
E.Paccagnini, A.M.Pucci, P.DI Sirnplicio,
"Studies on the biological effects of ozone: 9.
Effects of ozone on human platelets", Platelets
-10: 110-116 (1999).
M.F.Cbristman, R.W.Morgan, F.S.Jacobson,
B.N.Ames, "Positive control of a regulon for
defenses against oxidative stress and some heatshock
proteins in Salmonella typhimurium", Cell
a:75 3-762 (1985).
W.J.Mckinney, R.H.Jaskot, J.H.Richards,
D.L.Costa, K.L.Dreher, "Cytokine mediation of
ozone-induced pulmonary adaptation", Amer. J.
Respir. Cell Molec. Biol. Is: 696-705 (1998).
I.Rahrnan, L.B.Clerch, D.Massaro, "Rat lung
antioxidant enzyme induction by ozone", Amer.
J. Physiol. 260: L412-L418 (1991).
44. HSandermann, IIL, D.Ernst, W.Heller,
C.Langebartels, "Ozone: an abiotic elicitor of plant
defence reactions", Trend. Plant Sci. 1: 47-50 (1998).
45. Y.K.Sharrna, K.R.Davis, "The effects of ozone on
antioxidant responses in plants", Free Rad. Biol.
Med. 23: 480-488 (1997).
46. D.R.Spitz, W.C.Dewey, G.C.Li, "&irogen peroxide
or heat shock induces resistance to hydrogen
peroxide in chinese hamster fibroblasts", 1. Cell.
Physiol. 131: 364-373 (1987).
47. M.H.varcgas, L.Romero, B.Sommer, P.Zamudio,
P.Gustin, L.M.Montaiio, "Chronic exposure to ozone
causes tolerance to airway hyperresponsiveness in
guinea pigs: lack of SOD role", J. Appl. Physiol. 84:
1749-1755 (1998). ',
48. P.Wang, H.Chen, H.Qin, S.Sankarapandi,
M.W.Becher, P.C.Wong, J.L.Zweier,
"Overexpression of human copper, zinc-superoxide
dismutase (SOD1) prevents postischemic injury",
Proc. Nat. Acad. Sci. USA 95: 4556-4560 (1998).
49. M.Minetti, C.Mallozzi, A.M.M.Di Stasi,
D.Pietraforte, "Bilirubin is an effective antioxidant of
peroxynitrite-mediated protein oxidation in human
blood plasma", Arch. Biochem. Biophys. 352: 165-
174 (1998).
50. B.Halliwel1, "Antioxidants in human health and
disease", Annu. Rev. Nutr. 16: 33-50 (1996).
51. B.Halliwell, "Antioxidant defence mechanisms: from
the beginning to the end (of the beginning)", Free
Radic. Res. 2: 261 -272 (1 999).
52. H.H.Wolff, Dasmedizinische ozon. Theoretische
grundlagen, therapeutische anwedungen (Heidelberg:
Verlag fir Medizin, 1979).
53. V.Bocci, "Proposal of a new methodology for
performing a safe and atoxic ozonated
autohemotherapy (AHT)". In: F.Ceccherelli and F.
Giron (Eds.), L'Ozonoterapia nel 2000 (Torino:
Edizioni Libreria Cortina, 1999), pp. 11-24.
54. H.G.Knoch, W.Roschke, W.Klug, "OzoneIOxygen
therapy in proctology", OzoNachrichten 5: 5 1-70
(1987).
55. M.T.Carpen&le, J.Freeberg, J.Mcleod Griffiss.
"Does Ozone alleviate AIDS diarrhea?", J. Clin.
Gastroenterol. IZ : 142- 145 (1 993).
56. V.Bocci, E.Bonelli, F.Corradeschi, G.Valacchi,
"Systemic effects after colorectal insufflation of
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
216 V. Bocci et al.
oxygen-ozone", Z. Naturforsch. C. (2000).
Submitted.
.57. E.Payr, " h e r Ozonbehandlung in der
Chirurgie", Miinch. med. Wochenschr. 82: 220-
291 (1935).
58. P.Aubourg, "Ozon in der Chinugie", Mem.
Acad. Chir 65: 11 83-1 192 (1940).
59. S.J.Miroshin and C. N. Kontorshikova, "The use
of ozone therapy technology in the treatment of
modem war surgical trauma". In: The ozone in
biology and medicine. 2nd all Russian scientificpractical
conference, Septmber 6-8, 1995.
Russian association of ozone therapy,
Reshetnikovskaya street 2, Nizhni Novgorod,
603006 Russia 1995), pp. 16.
60. N.M.Shaschova, T. S. Kachalina, and A. L.
Nevmjatullin, "Application of ozonotherapy in
complex treatment of inner female genital
inflammatory diseases". In: INTERNATIONAL
OZONE ASSOCIATION (Eds.), Proceedings
Ozone in Medicine, 12th World Congress of the
International Ozone Association, 15th to 18th
May 1995, Lille France (Tours: Instaprint S.A.,
1995), pp. 145-155.
6 1. V.I.Bulinin, N. V. Solod, and I. P. Moshurov,
"The first experienc'e of chronic abscesses and
pleura emphyemas treatment by the method of
ozonization". In: The ozone in biology and
medicine. 2nd all Russian scientific-practical
conference, September 6-8, 1995. Russian
association of ozone therapy, Reshetnikovskaya
street 2, Nizhni Novgorod, 603006 Russia1995),
pp 20.
62. B.P.Kudravcev, S. J. Miroshin, and S. V.
Semyonov, "The use of ozonized solutions in
complex treatment of peritonitis". In: The ozone
in biology and medicine. 2nd all Russian
Scientific-Practical Conference, September 6-8,
1995, Russian Association of Ozone therapy,
Reshetnikovskaya stret, 2 - Nizhni Novgorod.
603006 Russia (Nizhni Novgorodl995). pp. 20.
63. S.A.Kasumjan, A. D. Lelyanov, E. D. 'Guseva,
and B. P. Alexeev, "The ozone therapy of the
acute suppurative infection". In: The ozone in
biology and medicine. 2nd all Russian scientificpractical
conference, September 6-8, 1995.
Russian association of ozone therapy,
Reshetnikovskaya street 2, Nizhni Novgorod,
603006 Russia1995), pp. 16.
V.Bocci, "A reasonable approach for the treatment of
HIV infection in the early phase with ozone therapy
(autohemotherapy). How inflammatory cytokines '
may have a therapeutic role", Mediat. hflamm. 3:
315-321 (1994).
V.Bocci, "Ozone therapy as a possible biological
response modifier in cancer", Forsch.
Komplementirmed. 5: 54-60 (1 998).
G.E.Garber, D.W.Cameron. N.Hawley-Foss,
D-Greenway, M.E.Shannon, "The use of ozonetreated
blood in the therapy of HIV infection and
immune disease: a pilot study of safety and
efficacy.", AIDS 2: 98 1-984 (1 99 1).
G.Valacchi, V.Bocci, "Studies on the biological
effects of ozone: 10.'- Release of factors from
ozonated human platelets", Mediat. Inflamrn. 8: 205-
209 (1999).
H.Werkmeister, "Dekubitalgeschwiire und die
Behandlung mit der Ozon-Unterdruckbegasung". In: ,
BECK and VIEBAHN-HANSLER (Eds.), Ozon-
Handbuck. Grundlagen. Pravention. Therapie
(Landsberg/Lech: Ecomed, 19959, pp. V-7.1 1 -V-7.1
22.
R.Wong, S. Menendez, J. Castaiier, P. Perez, and A.
Abreu, "Ozone therapy in ischemic cardiopathy". In:
International Ozone Association (Eds.), Proceedings
Ozone in Medicine 12th World Congress of the
International Ozone Association, 15th to 18th May
1995, Lille France (Tours: Instaprint, 1995), pp.73-
77.
G.H.Wasser, "Zerebrale Durchblutungsstorungen".
In: Beck and Viebahn-Hansler (Eds.), Ozon-
Handbuch. Grundlagen. Pravention. Therapie
(LandsbergLech: Ecomed, 1995), pp. V-6.3 1-V-6.3
12.
K.Kraft, E.Stenkamp, A.Sachinidis, S.Seewald,
H.Vetter, "Effect of autohemotherapy with ozone on
cardiovascular risk factors in patients with mild
hypertension", Perfision 1_1: 2 16-2 19 (1998).
F.Hernhdez. S.MenCndez, R.Wong, "Decrease of
blood cholesterol and stimulation of antioxidative
response in cardiopathy .patients treated with
endovenous ozone therapy", Free Radical Biol. Med.
-19: 115-1 19 (1995).
M.A.Gomez Moraleda, "Ozone therapy in the
functional recovery ffom diseases involving damage
to central nervous system cells". In: International
Ozone Association (Eds.), Proceedings Ozone in
Medicine 12th World Congress of th International
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
Ozone in Medicine 217
Ozone Association, 15th to 18th May 1995,
Lille, France. (Tours: Instaprint S.A., 1995),
pp.111-123.
C.-H.Siemsen, "Ozon-Anwendung bei akuten
und chronischen Gelenkerkrankungen". In: Beck
and Viebahn-Hbsler (Eds.), Ozon-Handbuch.
Grundlagen. Pravention. Therapie
(LandsbergLech: Ecomed, 1995), pp. V-9.2 IV-
9.2 14.
A.Alexandre and G. Fumo, "Discolisi percutanea
mediante 0,0, nell'ernia &scale lombare". In:
F.Ceccherelli and A. Ricciardi (Eds.), Lombalgie
e lombosciatalgie. Criteri di diagnosi e cura
(Torino: Edizioni Libreria Cortina, 1998),
pp.367-377.
V.Bocci, "Ipotetici meccanismi di azione
dell'ozono nel trattarnento del conflitto
discoradicolare". In: F.Ceccherel1i and A.
~icciard(~Ed s.), Lombalgie e lombosciatalgie.
Criteri di diagnosi e cura (Torino: Edizioni
Libreria Cortina, 1998), pp.33 1-340.
M.Brayda-Bruno and P. Cinnella, "I1 trattarnento
dell'ernia discale con infiltrazioni di ossigenoozono
in paravertebrale". In: F.Ceccherelli and
A. Ricciardi (Eds.), Lombalgie e
lombosciatalgie. Criteri di diagnosi e cura
(Torino: Edizioni Libreria Cortina, 1998),
pp.361-365.
V.Bocci, "Determinants of erythrocyte ageing: a
reappraisal.", Brit. J. Haematol. 48: 515-522
(1981).
E.Marshal1, "Gene therapy on trial", Science
-288: 95 1-957 (2000).
Downloaded By: [TÜBTAK EKUAL] At: 13:18 13 February 2009
Mevcut yazılı metin bilgilendirme amaçlıdır. Bilimsel verilerden elde edilmiş bilgilerdir. Konu hakkında uzman kişiler tarafından yönlendirilmeniz ve tedaviye yönelik işlemleri bir hekim kontrolünde uygulamanız veya uygulatmanız önerilir.