【作者】 谢燕清；

【导师】 谢赖克；

【作者基本信息】 广州医学院 ， 呼吸内科学， 2011， 博士

【摘要】 研究背景变应性鼻炎（allergic rhinitis,AR）是一种由易感个体接触致敏变应原后由IgE抗体参与、以肥大细胞释放介质（主要是组胺等）为开端、有多种免疫活性细胞和细胞因子等共同作用的鼻粘膜慢性炎症性疾病。变应性鼻炎和哮喘均属于气道变应性疾病,两者发病密切相关。1997年Grossman首先明确提出“同一气道,同一疾病”的论点,强调呼吸道炎症性疾病整体性的概念。2001年世界卫生组织编写出版的指导性文件“变应性鼻炎及其对哮喘的影响”（allergic rhinitits and its impact on asthma,ARIA）指出变应性鼻炎是导致哮喘的主要因素之一,ARIA 2008年修订本更加明确阐述“变应性鼻炎与哮喘是一个综合征在呼吸道两个部分的表现”这一基本原则,可见将二者作为整体进行研究具有重要意义。变应性鼻炎和哮喘均属于气道变应性疾病,两者的免疫病理学发病机制非常类似,均表现为以气道嗜酸性粒细胞（Eos）浸润为特征的变应性炎症。目前,下气道嗜酸性粒细胞性炎症检测已有成熟的客观方法——诱导痰细胞分类检测法,但反映上气道嗜酸性粒细胞性炎症情况的检测方法——鼻灌洗检查则因评估方法、阳性判断等方面未有统一标准,使其临床应用明显受限,未能成为上气道炎性疾病临床诊断及追踪监测的常规方法。变应性鼻炎在世界范围内的患病率近年来呈上升趋势,它影响患者生活质量、增加社会经济负担,现已成为全球性的健康问题。但目前国际或国内大型流行病学调查得到的数据大多只是通过问卷或电话访问,以患者的自觉症状作为判断,缺乏客观可比的检查指标。变应性与非变应性鼻炎在症状上有很多相似之处,单凭症状难以将两者明确区分,在这些自报患病的人群中,变应性与非变应性鼻炎的分布比例难以确定,这势必影响变应性鼻炎患病率调查数据的准确性及科学性,因此有待专项研究深入探讨;而不同鼻炎与哮喘等相关疾病的联系国内也鲜见报道。此外,近年来越来越多研究表明变应性鼻炎（AR）和非变应性鼻炎（NAR）均与哮喘发生发展密切相关,但目前国内外仍缺乏对无下气道症状的变应性或非变应性鼻炎患者下气道炎症和高反应性特征比较的大样本研究。“不同鼻炎病人上下气道炎症和高反应性的特征有何异同?上下气道炎症、下气道炎症与高反应性之间是否存在一定的内在联系?在鼻炎病人尚未出现下气道症状的阶段,能否通过评价某些全身或上下气道变应性炎症的指标而预测下气道高反应性发生的风险?”等一系列临床问题仍未得到解答,在国内外文献亦均未见报导,仍有待更多客观、科学、严谨的临床实验深入研究。因此本研究拟通过对大样本正常和变应性鼻炎人群鼻灌洗液的收集和处理,系统地分析比较鼻灌洗液细胞成分分布特点,建立鼻灌洗液细胞分类评价方法及其正常值标准,评价该法在变应性鼻炎辅助诊断中的临床价值;通过对广东某高校进行大学生鼻炎及其相关疾病抽样调查,结合耳鼻喉专科检查及变应原临床检测技术,以明确广东地区大学生鼻炎患病率情况,评估在自报患病的鼻炎人群中变应性与非变应性鼻炎的分布比例及其与哮喘关系;最后通过对变应性、非变应性鼻炎患者及健康正常人进行血常规、鼻灌洗、诱导痰、呼出气一氧化氮、支气管激发试验等临床检查,明确无下气道症状的变应性鼻炎和非变应性鼻炎病人的炎症特征及其与下气道炎症及高反应性的关系;探索上下气道炎症、下气道炎症与高反应性之间的内在联系;在鼻炎病人尚未出现下气道症状的阶段,寻求某些外周血或上、下气道变应性炎症指标用以预测下气道高反应性发生的风险,为鼻炎和哮喘的临床监测、早期干预和控制提供科学依据。目的:建立鼻灌洗液细胞分类方法及其正常值标准,评价该法在变应性鼻炎辅助诊断中的临床价值。方法:于2009年1月～2011年1月招募在某高校就读的健康学生及到本院体检中心体检的健康成人志愿者为正常组,入选志愿者体格检查、血常规、胸部X线透视及肺通气功能检查均未见异常,变应原皮肤点刺试验且血清吸入性过敏原筛查检测呈阴性反应;招募具有典型变应性鼻炎症状及体征的患者为变应性鼻炎组,诊断标准参照ARIA-2008,入选患者4周内均未口服或鼻用或吸入激素和抗组胺药物;所有受试者均无慢性咳嗽或喘息及其他系统慢性疾病病史,近8周无呼吸道感染病史,无鼻部及颜面部外伤史,无吸烟史,鼻窥镜检查无明显鼻中隔偏曲,女性患者均不处于妊娠期或哺乳期。本研究经本院医学伦理委员会审批同意,测试前所有患者和健康志愿者均被告知本研究内容后同意参加并签署知情同意书。两组受试者均进行鼻灌洗检查,鼻灌洗液细胞沉淀在光学显微镜下进行炎症细胞分类计数及分类百分比计算。以200倍视野下是否可见上皮细胞或炎症细胞作为鼻灌洗成败的标志。在20个互相不重复的200倍视野下分别计算中性粒细胞、巨噬细胞、嗜酸性粒细胞和淋巴细胞的个数,以其平均值作为炎症细胞分类计数值;以中性粒细胞% =20个视野下中性粒细胞之和/20个视野下炎症细胞之和×100%计算炎症细胞分类百分比,同理算出巨噬细胞、嗜酸性粒细胞和淋巴细胞的分类百分比。比较两种评价方法在正常组和变应性鼻炎组之间的差异,确立鼻灌洗液细胞分类的最佳阳性判定指标;建立本研究健康成人鼻灌洗液炎症细胞分类计数95%参考值上限;采用非参数法构建ROC曲线,并以Youden指数最大切点为临界点,计算对应的敏感度和特异度,评价该法的临床诊断价值。结果:1.入选正常组162例和变应性鼻炎组184例,组间的性别构成比及年龄、身高、体重及体重指数（BMI）均无显著性差异（P>0.05）,证明两组间具有可比性。2.以200倍视野下是否可见上皮细胞或炎症细胞作为鼻灌洗成败的标志,正常组鼻灌洗检查成功率为98.77%,变应性鼻炎组为98.91%,两组间无显著性差异（P>0.05）。3.鼻灌洗液里除上皮细胞外有炎症细胞者,正常组53例（33.12%）,变应性鼻炎组155例（85.16%）,两组间有显著性差异（P<0.01）;对两组鼻灌洗液中有炎症细胞的标本进行比较,各炎症细胞百分比在两组间均无显著性差异（P>0.05）。4.正常组鼻灌洗液中性粒细胞和嗜酸性粒细胞计数分别为1.74±9.37、0.76±3.46个/×200（HE）,与变应性鼻炎组13.61±46.93、27.88±62.47个/×200（HE）比较均有非常显著性差异（P<0.01）;本研究健康成人鼻灌洗液中性粒细胞及嗜酸性粒细胞分类计数95%参考值上限分别为10.03、3.47个/×200（HE）。5.以变应性鼻炎临床诊断标准为金标准,分别以鼻灌洗液中性粒细胞计数或嗜酸性粒细胞计数作为阳性判定指标作出ROC曲线,显示酸粒细胞计数是鼻灌洗液细胞分类最佳的阳性判定指标,其曲线下面积为0.86（P<0.01）,最佳临界值为0.35个/×200（HE）,对应的敏感度为0.76,特异度为0.89,Youden指数为0.66,阳性拟然比为7.21,阴性拟然比为0.14。结论:1.鼻灌洗液炎症细胞分类绝对计数法能明确区分正常人和变应性鼻炎病人,可作为变应性鼻炎临床辅助诊断的评价方法。2.鼻灌洗液嗜酸性粒细胞计数是鼻灌洗检查辅助变应性鼻炎诊断时最佳的阳性判定指标,其95%参考值上限为3.47个/×200（HE）。目的:明确大学生鼻炎患病率情况,评估在自报患病的鼻炎人群中变应性与非变应性鼻炎的分布比例及其与哮喘关系。方法:通过《广东地区大学生鼻炎及其相关疾病调查问卷》在广东某高校进行抽样调查,包括人口学特征、家族史、鼻炎相关症状、哮喘相关症状、咳嗽症状及特征、眼部相关症状及皮肤症状等。由经过统一培训的调查员以统一的调查方式对所有研究对象进行一对一问卷访谈。初步筛选部分出具有鼻分泌物、喷嚏、鼻塞、鼻痒等任一症状或病史的可疑鼻炎患者及无任何不适症状的健康受访者到本院接受耳鼻喉专科检查和临床检测,结合丹麦ALK公司提供的11种常见吸入性变应原进行皮肤点刺试验及瑞典pharmacia公司提供Phadiatop试剂盒进行血清吸入性变应原sIgE检测进行临床确诊,共分为变应性鼻炎、非变应性鼻炎、特应质或健康正常4组;变应性鼻炎诊断及分类、分度标准参照2008年ARIA指南进行。按统一数据库结构变量定义表,将全部问卷调查表资料数据输入统一格式的excel表格,并进行2人次以上交叉核对。采用SPSS13.0统计分析软件进行资料的整理和分析,率的比较采用χ2检验。结果:1.共发放问卷2362份,回收有效问卷2339份,应答率为99.03%;广东地区大学生鼻炎患病率为19.20%,男女患病率差异无统计学意义;无任何变应性疾病症状的健康正常人1357例（58.02%）;特应性皮炎534例（22.83%）、变应性眼结膜炎201例（8.59%）、鼻窦炎85例（3.63%）、哮喘35例（1.50%）。2.鼻炎患者平均病程为4.48±3.64年,最短0.5年、最长20年。其中过去一年鼻炎无发作75例（16.70%）、间歇性250例（55.68%）、持续性124例（27.62%）;轻度149例（33.18%）、中重度300例（66.82%）。3.鼻炎患者主要症状依次为:打喷嚏287例（63.92%）、流清鼻涕264例（58.80%）、鼻塞239例（53.23%）、鼻痒205例（45.66%）。4.鼻炎发作主要规律依次为:季节交替131例（29.18%）、冬季109例（24.28%）、常年不断62例（13.81%）、春季48例（10.69%）、夏季33例（7.35%）、秋季24例（5.35%）;无规律70例（15.59%）。5.诱发鼻炎的主要因素依次为:冷空气274例（61.02%）、灰尘180例（40.09%）、刺激性气体144例（32.07%）、猫狗或有毛动物50例（11.14%）、花草43例（9.58%）、饮食36例（8.02%）、运动29例（6.46%）、青霉素4例（0.89%）、阿司匹林1例（0.22%）;其他原因60例（13.36%）包括天气变化、空气浑浊、晨起或睡前、香水或化妆品、吸二手烟等。6.鼻炎患者有变应性疾病家族史221例（49.22%）,发生率依次为:变应性鼻炎132例（29.40%）、食物过敏70例（15.59%）、哮喘26例（5.79%）、特异性皮炎21例（4.68%）、变应性眼结膜炎14例（3.12%）。7.鼻炎常见合并疾病依次为:特异性皮炎138例（30.73%）、变应性眼结膜炎79例（17.59%）、鼻窦炎43例（9.58%）、哮喘32例（7.13%）、慢性咳嗽8例（1.78%）。8.进行变应原皮肤点刺试验及sIgE检测后,250例具有鼻炎症状患者出现阳性136例（54.40%）,阴性114例（45.60%）;168例无变应性疾病症状正常人出现阳性27例（16.07%）,阴性141例（83.93%）。9.鼻炎组最多见的前3种变应原分别为屋尘螨、粉尘螨和热带螨;正常组发生反应的变应原种类及程度均与鼻炎组有显著性差异,P<0.05。10.各组哮喘患病率分别为:变应性鼻炎组22.52%、非变应性鼻炎组6.54%、特应质组8%和正常组0.71%,其中变应性鼻炎组与正常组比较有非常显著性差异（P<0.01）,非变应性鼻炎组与正常组比较有显著性差异（P<0.05）。结论:1.广东地区大学生鼻炎患病率高达19.2%,其中非变应性鼻炎与变应性鼻炎比例相当。2.变应性鼻炎和非变应性鼻炎人群中哮喘患病率均有增高,显示两者均为增加哮喘患病风险的危险因素。目的:明确无下气道症状的变应性鼻炎和非变应性鼻炎病人的炎症特征及其与下气道炎症及高反应性的关系。方法:于2009年1月～2011年1月招募到本院耳鼻喉科门诊就诊的具有典型变应性鼻炎症状及体征、变应原皮肤点刺试验或血清吸入性过敏原筛查检测呈阳性反应的患者为变应性鼻炎组（AR组）,诊断标准参照ARIA-2008;招募具有典型变应性鼻炎症状及体征、变应原皮肤点刺试验且血清吸入性过敏原筛查检测呈阴性反应的患者为非变应性鼻炎组（NAR组）;入选的鼻炎患者4周内均未口服或鼻用或吸入激素和抗组胺药物。招募在某高校就读的健康学生及到本院体检中心体检的健康成人志愿者为健康正常组（正常组）,入选志愿者体格检查、血常规、胸部X线透视及肺通气功能检查均未见异常,变应原皮肤点刺试验且血清吸入性过敏原筛查检测呈阴性反应。所有受试者均无慢性咳嗽或喘息及其他系统慢性疾病病史,近8周无呼吸道感染病史,无鼻部及颜面部外伤史,无吸烟史,鼻窥镜检查无明显鼻中隔偏曲,女性患者均不处于妊娠期或哺乳期。本研究经本院医学伦理委员会审批同意,测试前所有患者和健康志愿者均被告知本研究内容后同意参加并签署知情同意书。三组受试者均进行外周血细胞五分类检查（外周血Eos计数>0.30×109/L为阳性）、呼出气一氧化氮检测（FeNO>25ppb为阳性）、鼻灌洗液炎症细胞分类检查（鼻灌洗Eos计数>3.47个/×200为阳性）、肺通气功能检查、乙酰甲胆碱支气管激发试验（FEV1下降≥15%为可疑阳性、>20%为阳性）和诱导痰细胞分类检查（诱导痰Eos比例>2.5%为阳性）。比较三组外周血及上下气道炎症、气道高反应性的特征及差异。两组间比较采用t检验,多组间比较采用单因素方差分析（ANOVA）;率的比较采用χ²检验的连续校正法;应用Logisitic多元回归分析确定增加下气道Eos炎症和高反应性发生风险的危险因素。结果:1.入选AR组184例、NAR组129例和正常组162例,三组间的性别构成比及年龄、身高、体重及体重指数（BMI）均无显著性差异（P>0.05）,证明三组间具有可比性。2. AR组、NAR组和正常组外周血Eos比率分别为3.34±2.26% vs 2.49±1.79% vs 1.81±1.22%（P<0.01）;外周Eos计数分别为0.20±0.16×10⁹/L vs 0.16±0.13×10⁹/L vs 0.10±0.07×10⁹/L（P<0.01）;三组外周血Eos计数阳性率分别为17.79% vs 14.06% vs 1.96%（P<0.01）。3. NAR组鼻灌洗液中性粒细胞计数为48.28±141.17个/×200,与AR组13.61±46.93个/×200和正常组1.74±9.37个/×200比较均有非常显著性差异（P<0.01）;AR组鼻灌洗液Eos计数为27.88±62.47个/×200,与NAR组9.04±22.56个/×200和正常组0.76±3.46个/×200比较均有非常显著性差异（P<0.01）;三组鼻灌洗液Eos计数阳性率分别为59.89% vs 28.35% vs 5%（P<0.01）。4. AR组诱导痰Eos比例为4.84±8.63%,与NAR组1.29±3.23%和正常组0.37±0.91%比较均有非常显著性差异（P<0.01）;三组诱导痰Eos比例阳性率分别为38.32% vs 13.93% vs 1.42%（P<0.01）。5. AR组FeNO为25.82±18.58 ppb,与NAR组17.77±11.93 ppb和正常组14.15±6.79 ppb比较均有非常显著性差异（P<0.01）;AR组FeNO阳性率为34.07%,与NAR组15.15%和正常组6.25%比较均有非常显著性差异（P<0.05）。6.三组间各肺通气功能主要指标均无显著性差异（P<0.05）;AR组支气管激发试验可疑阳性+阳性率为11.96%,与NAR组2.33%、正常组1.23%比较均有非常显著性差异（P<0.01）。7.将变应性鼻炎组以是否存在上气道Eos炎症分为两层,有上气道Eos炎症和无上气道Eos炎症层诱导痰Eos百分比阳性率分别为48.41%vs7.50%（P<0.01）。8.将非变应性鼻炎组以是否存在上气道Eos炎症分为两层,有上气道Eos炎症和无上气道Eos炎症层诱导痰Eos百分比阳性率分别为26.23% vs 1.69%（P<0.01）。9.经Logistic多元回归可获下气道Eos炎症影响因素的Logistic多元回归预测方程:Logit（P）= -4.781+1.410X₁+2.274X₂+2.797X₃+1.134X₄,其中X1为变应原测定;X₂为外周血Eos计数;X3为鼻灌洗Eos计数;X₄为支气管激发试验。增加下气道Eos炎症发生的危险因素分别是:变应原测定阳性（OR=4.096）、外周血Eos计数升高（OR=9.715）、鼻灌洗液Eos计数升高（OR=16.398）和支气管激发试验可疑/阳性（OR=3.107）。10.经Logistic多元回归可获BHR影响因素的Logistic多元回归预测方程:Logit（P）= -4.167+1.453X₁+1.587X₂,其中X₁为变应原测定;X₂为诱导痰Eos比例。增加BHR的危险因素分别是:变应原测定阳性（OR=4.276）和诱导痰Eos比例升高（OR=4.890）。结论:1.部分无下呼吸道症状变应性鼻炎病人存在下气道炎症及气道高反应性;2.部分无下呼吸道症状非变应性鼻炎病人存在下气道炎症;3.上气道Eos炎症是导致下气道Eos炎症的主要独立高危因素;4.特应性体质和下气道Eos炎症是气道高反应性的独立危险因素。全文主要结论:1.建立了鼻灌洗液炎症细胞分类评价方法,炎性细胞绝对计数法能明确区分正常人和变应性鼻炎病人;嗜酸性粒细胞计数是鼻灌洗检查辅助变应性鼻炎诊断时最佳的阳性判定指标,其95%参考值上限为3.47个/×200（HE）。2.广东地区大学生鼻炎患病率高达19.2%,其中非变应性鼻炎与变应性鼻炎比例相当;变应性鼻炎和非变应性鼻炎人群中哮喘患病率均有增高,显示两者均为增加哮喘患病风险的危险因素。3.证实了缺乏下气道症状的部分变应性和非变应性鼻炎患者存在下气道嗜酸性粒细胞炎症或下气道高反应性,这可能是鼻炎发展为哮喘的早期阶段。更多还原

【Abstract】 Background and ObjectiveAllergic rhinitis （AR） is the chronic inflammatory disease of nasal mucus triggered by IgE antibody-mediated release of inflammatory mediators （mainly histamine） by mast cells under comorbid actions of multiple immuno-active cells and cytokines after contact with allergens in susceptible individuals. Categorized as airway allergic diseases, both allergic rhinitis and asthma share close correlations. In 1997, Grossman et al first proposed the concept of‘One airway, one disease’, which emphasized the integraty of respiratory inflammatory diseases. In 2001, World Health Organization published a guideline document entitled‘allergic rhinitits and its impact on asthma’（ARIA）, in which allergic rhinitis was stated as one of the major factor contributing to asthma. Furthermore, a 2008 update of ARIA stated the principle more explicitly that allergic rhinitis and asthma are both manifestation of a syndrome in two separate airway positions, which indicated the significance of integration of both diseases. Both allergic rhinitis and asthma share numerous similarities in immunopathological pathogenesis and are characterized of airway eosinophil infiltration. Induced sputum cytology test is currently a mature objective approach for measurement of lower airway eosinophilic inflammation, while nasal lavage cytology test could well represent upper airway inflammation, which lacks unified standard for evaluation as well as positive threshold. Its limitation in clinical applications has led to the failure of being a routine method for clinical diagnosis of upper airway inflammatory diseases and follow-up visits.With a growing trend in worldwide prevalence rate, allergic rhinitis has exerted its impact on the quality of life, loaded huge social economic burden and has become a global health issue. To date, most international or national epidemiological data were obtained mainly through questionnaire surveys or telephone investigations, judgments were made only according to subject’s own perceptions, and there is a lack of objective and comparable parameter for the measurements. From the perspective of symptom, various similarities are present in allergic and non-allergic rhinitis, which made distinction demanding solely on symptoms. The difficulty in determining the proportion of AR and non-allergic rhinitis （NAR） in these self-reported subjects would lead to adverse impact on the accuracy and scientificity of investigation data on prevalence of allergic-rhinitis, for which further studies need to be conducted. Moreover, few studies were available concerning the prevalence of rhinitis and asthma in China.Furthermore, although close correlation between AR and NAR has been suggested by more and more recent studies, there’s a lack of large scale comparison on the characters of lower airway inflammation and hyperresponsiveness in subjects with simple AR or NAR. Clinical issues, for instance, whether NAR shares identical risk factors for development of disease with bronchial asthma, or could the risk of lower airway hyperresponsiveness be predicted through assessment of systemic and lower airway allergic inflammation prior to existence of lower airway symptoms in subjects with rhinitis are yet to be solved. No report was available around the world, therefore more objective, scientific and prudent clinical trials are to be carried out. In this study, the distribution character of cell components was analyzed systematically, the approach for assessment of cell differentiation and related normal reference values were established, and clinical significance in assisting the diagnosis of AR was evaluated through collection and processing of nasal lavage fluid in a large scale of normal individuals and subjects with AR. The prevalence of rhinitis in college students of Guangdong could be determined, and the proportion of AR and NAR as well as the correlation with occurrence of asthma in subjects with self-reported rhinitis were assessed thourgh sampling survey on rhinitis and its related disorders in a sampled college in combination with otolaryngopharyngologic examinations as well as measurements of allergens in clinics. In the last section, the inflammatory characters of subejcts without lower airway symptoms who had AR or NAR and its correlation with lower airway inflammation and hyperresponsiveness were determined through blood routine test, nasal lavage test, induced sputum test, measurement of exhaled nitric oxide and bronchial provocation test in subejcts with AR, NAR as well as normal individuals. The intrinsic correlation between upper airway inflammation, lower airway inflammation and hyperreposniveness was also explored. The parameters of peripheral blood or upper/ lower airway allergic inflammation were identified for prediction of the risk of lower airway hyperesponsiveness prior to occurrence of lower airway symptoms in subjects with rhinits, thereby offering scientific proves for clinical monitor, early intervention and control of rhinitis and asthma. ObjectivesTo establish the methodology for nasal lavage cytology differential test and the normal reference range, and assess the clinical significance in assissting diagnosis of allergic rhinitis.MethodsNormal healthy students in a college of Guangzhou and adult volunteers recruited in The Physical Examination Center, The First Affiliated Hospital of Guangzhou Medical College from January 2009 to January 2011 were enrolled in the study as normal subjects. No abnormality in physical examination, blood routine test, chest X-ray roentgenography or spirometric test was revealed, and allergen skin prick test proved negative in normal controls. Subjects with typical symptoms and signs of allergic rhinitis were recruited in allergic rhinitis group according to the diagnostic criteria of ARIA 2008, who should had no use of oral or intranasal corticosteroid or anti-histamine. All subjects had neither history of chronic cough, wheezing or other systemic disease, nor upper respiratory tract infection for the past 8 weeks, and had neither the history of nasal or facial injury nor smoking. No intranasal septum deviation was revealed by nasal speculum examination. All female subjects must not be within pregnancy or lactation period. The protocol was approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical College. The items of the study were interpreted to all subjects, and informed written consent was given prior to the study. Nasal lavage procedures were performed in both groups of subjects. Inflammatory cells and their percentages in the sediments of nasal lavage fluid were calculated under microscopic vision, with the standard of whether epithelial cells or inflammatory cells were visible under 200×microscopic vision for judgment of quality of test. Neutrophils, macrophages, eosinophilss and lymphocytes were counted in 20 non-repeated fields under 200×microscopic vision, with the averages being the cell counts of inflammatory cells. Percentage of neutrophils was calculated using the formula: sum of neutrophils in 20 fields/ sum of inflammatory cells in 20 fields×100%, and percentages of macrophages, eosinophilss and lymphocytes were deduced following the identical approach. Distinction of the two measurements in normal control group and allergic rhinitis group was compared in order to establish the optimal parameter for judgment of positive outcomes of nasal lavage test. The 95% upper reference limit of inflammatory cells was calculated for normal individuals. Receiver operation characteristic curve （ROCC） was depicted adopting non-parametric approach, and the threshold was determined according to the maximal Youden’s index. The corresponding sensitive and specificity were calculated for evaluation of the significance of clinical diagnosis.Results1. We enrolled 162 healthy volunteers and 184 subjects with allergic rhinitis. No statistical difference （P>0.05） was revealed in constitutional proportion of gender, age, height, weight and body mass index （BMI）, which indicated comparability between two groups.2. According to the existence of epithelial cells or inflammatory cells visible under 200×microscopic vision as successful standard of test, the successful rate of nasal lavage test was 98.77% and 98.91% in normal control group and allergic rhinitis group, with no significant difference （P>0.05） being found between two groups.3. Besides epithelial cells, inflammatory cells were visible in nasal lavage fluid among 53 subjects （33.12%） in normal control group and 155 subjects in AR group （85.16%）, with significant statistical difference （P<0.01） between both groups. No statistical difference （P>0.05） was shown in the percentage of each inflammatory cell between the two groups.4. The neutrophil and eosinophil count was 1.74±9.37 /×200 and 0.76±3.46 /×200 （HE stain） in normal control group, with significant statistical diffenrece （P<0.01） compared with that of AR group [13.61±46.93/×200 and 27.88±62.47 /×200 （HE stain）], respectively. The 95% upper reference limit of inflammatory cells in nasal lavage test was 10.03/×200 for neutrophils and 3.47/×200 for eosinophils （HE stain） in healthy volunteers, respectively.5. The clinical diagnostic criteria were set as the golden standard for allergic rhinitis, and ROC curves were depicted based on the positive standard using neutrophil or eosinophil counts in nasal lavage fluid, with the results revealing eosinophil count to be the optimal positive criterion （area under curve: 0.86, P<0.01） . The optimal threshold of eosinophil count in nasal lavage fluid for allergic rhinitis was 0.350/×200 according to ROC curve, with the sensitivity, specificity, Youden’s index, positive likelihood ratio and negative likelihood ratio of 0.76, 0.89, 0.66, 7.21 and 0.14, respectively.Conclusions1. Nasal lavage inflammatory cell absolute count is capable of offering clear discrimination between normal individuals and subjects with allergic rhinitis, and may serve as a surrogate assessment toll for clinical diagnosis.2. Eosinophils count is the optimal positive parameter for judgment of the results of nasal lavage test, with the 95% upper reference limit of 3.47 /×200 （HE stain）. ObjectivesTo determine the prevalence rate of rhinitis in college students and assess the proportion of allergic rhinitis and non-allergic rhinitis in subjects with self-reported rhinitis as well as its correlation with occurrence of asthma.MethodsA sampling survey was performed in a college of Guangdong using‘Questionnaire on rhinitis and its complications in college students of Guangdong region’, with the items including epidemiological characters, family history, rhinitis-associated symptoms, asthma-associated symptoms, cough symptoms and its character, ocular region-associated symptoms and dermal symptoms, etc.. A one-to-one questionnaire survey using uniform method was conducted in all subjects enrolled in the study by investigators who underwent uniform training course. Subjects with any symptom of nasal secretion, sneezing, nasal congestion or itchy nose, or had susceptible history of rhinitis as well as the healthy volunteers without discomforts were primarily screened. The clinical diagnoses were made according to the skin prick test result using 11 common inhaled allergens （ALK Co. Ltd, Denmark） and measurement of serum specific IgE （sIgE） of inhaled allergens （Pharmacia kits, Phadiatop Co. Ltd, Switzerland）, therefore 4 groups （AR, NAR, atopy and normal control group） were divided. The diagnosis, classification and severity of AR took reference on the guideline of ARIA （version 2008）. Data of all questionnaires were defined according to the variables in uniform database structure, and were input into Excel TM electronic tables, with at least 2 personnels performing corss-checks. SPSS 13.0 was adopted for data reorganization and analysis. And chi-square test was applied for comparison of rates. Results1. 2362 questionnaires were delivered to the subjects, with 2339 valid questionnaires and the response rate of 99.03%. The prevalence rate of rhinitis was 19.20% in college students of Guangdong, with no statistical difference between genders. Among all individuals in normal control group, 1357 subejcts （58.02%） had no symptoms of allergic disorders, 534 subjects had atopic dermatitis （22.83%）, 201 subjects had allergic conjunctivitis （8.59%）, 85 subjects had sinusitis （3.63%）, and 35 subejcts had asthma （1.50%）.2. The prevalence rate of rhinitis in college students of Guangdong region was 19.20%, with no statistical difference between genders.The average span of rhinitis was （4.48±3.64） years,with the minimum and maximum of 0.5 year and 20 years. There were 75 （16.70%）, 250 （55.68%） and 124 （27.62%） subjects without episode, with intermittent episodes and continuous episodes of rhinitis in the last year, respectively. 149 （33.18%） and 300 （66.82%） subjects had mild and moderate-to-severe rhinitis.3. The major symptoms followed the sequence of sneezing [287 cases （63.92%）], running clear secretion [264 cases （58.80%）], nasal congestion [239 cases （53.23%）] and itchy nose [205 cases （45.66%）] in subjects with rhinitis.4. The major pattern of rhinitis episode followed the sequence of seasonal alternative [131 cases （29.18%）], in winter [109 cases （24.28%）], perennial continuous [62 cases （13.68%）], in spring [48 cases （10.69%）], in summer [33 cases （7.35%）], in autumn [24 cases （5.35%）] and irregular [70 cases （15.59%）].5. The major triggering factors of rhinitis followed the sequence of cold air [274 cases （61.02%）], dust contact [180 cases （40.09%）], stimulus gas contact [144 cases （32.07%）], contact with cat and dog or animals with furs [50 cases （11.14%）], flower or grass contact [43 cases （9.58%）], ingestion of food [36 cases （8.02%）], exercise [29 cases （6.46%）], contact with penicillin [4 cases （0.89%）], contact with aspirin [1 case （0.22%）], and other causes [60 cases in total （13.36%）], which included climate changes, air pollution, in the morning or prior to sleeping, contact with fragrance or cosmetics, and second-hand smoking, etc.6. There were 221 subjects （49.22%） with rhinitis reported family history of allergic disorders, with the incidence rates following the sequence of allergic rhinitis [132 cases （29.40%）], food allergy [70 cases （15.59%）], asthma [26 cases （5.79%）], atopic dermatitis [21 cases （4.68%）] and allergic conjunctivitis [14 cases （3.12%）].7. Common complications of rhinitis followed the sequence of atopic dermatitis [138 cases （30.73%）], allergic conjunctivitis [79 cases （17.59%）], sinusitis [43 cases （9.58%）], asthma [32 cases （7.13%）] and chronic cough [8 cases （1.78%）].8. Among 250 subjects with symptoms of rhinitis, allergen skin prick test and measurement of sIgE proved positive in 136 subejcts （54.40%） and was negative in 114 subjects （45.60%）. Among 168 normal individuals without symptoms of allergic disorders, allergen skin prick test and measurement of sIgE proved positive in 27 subejcts （16.07%） and was negative in 114 subjects （83.93%）.9. The three most common allergens in rhinitis groups were Dermatophagoides pterynyssinus, Dermatophagoides farinae and Dermatophagoides tropicalis, respectively. Significant statistical difference （P<0.05） was shown in the sort of allergens and the extent of reaction in normal individuals compared with that of rhinitis groups.10. The prevalence rate of asthma was 22.52%, 6.54%, 8.00% and 0.71% in AR, NAR, atopy and normal control group, respectively. Significant statistical difference （P<0.01） was revealed in the prevalence rate between AR group and normal control group. Statistical difference （P<0.05） was also shown between NAR group and normal control group.Conclusions1. The prevalence rate of rhinitis reaches to 19.20%, with a similar proportion of non-allergic rhinitis and allergic rhinitis.2. An increase in prevalence rate of asthma in subejcts with AR and NAR has been revealed, both of which are the predisposing factors of onset of asthma. ObjectivesTo determine the inflammatory character of allergic rhinitis and non-allergic rhinitis in subjects without lower airway symptoms and its correlation with lower airway inflammation and airway hyperresponsiveness.MethodsAll subjects were recruited from the outpatient clinics of otolaryngopharyngology department, The First Affiliated Hospital of Guangzhou Medical College from January 2009 to January 2011. Subjects with typical symptoms and signs of allergic rhinitis as well as positive allergen skin prick test result were allocated in allergic rhinitis group （AR） according to the diagnostic criteria of ARIA 2008, while subjects with typical symptoms and signs of allergic rhinitis as well as negative allergen skin prick test result were allocated in non-allergic rhinitis group. All subjects enrolled in the study should have no use of oral or intranasal corticosteroid or anti-histamine for the past 4 weeks. Normal healthy students in a college of Guangzhou and adult volunteers recruited in The Physical Examination Center, The First Affiliated Hospital of Guangzhou Medical College were allocated in the normal control group. No abnormality in physical examination, blood routine test, chest X-ray roentgenography or spirometric test was revealed, and allergen skin prick test proved negative in normal controls. All subjects enrolled had neither history of chronic cough, wheezing or other systemic disease, nor upper respiratory tract infection for the past 8 weeks, and had neither the history of nasal or facial injury nor smoking. No intranasal septum deviation was revealed by nasal speculum examination. All female subjects must not be within pregnancy or lactation period. The protocol was approved by the Ethics Committee of The First Affiliated Hospital of Guangzhou Medical College. The items of the study were interpreted to all subjects, and informed written consent was given prior to the study.Peripheral five-classify blood examinations （eosinophil count >0.30×109/L as positive criterion）, measurements of exhaled nitric oxide concentration （FENO> 25ppb as postive criterion）, nasal lavage fluid differentiation cytology tests （eosinophil count >3.47 /×200 as positive criterion）, spirometry tests, methacholine bronchial provocation tests （a≥15% and≥20% fall in FEV1 as susceptive positive and positive criterion, respectively） and induced sputum differential cytology tests （eosinophil percentage >2.5% as positive criterion） were performed. The character and difference in peripheral blood cells, systemic, upper and lower airway inflammation as well as airway hyperresponsiveness among three groups were compared. T-test, one-way analysis of variance （ANOVA） and chi-square continuous correction test was adopted for comparison between two groups, among multiple groups, and comparison on rates, respectively. Multiple variance Logistic regression was applied to determine the predisposing factors of lower airway hyperresponsiveness and eosinophils-associated inflammation.Results1. We enrolled 184 subjects with allergic rhinitis, 129 subjects with non-allergic rhinitis and 162 normal controls. No significant difference （P>0.05） in the constitutional proportion of gender, height, weight and body mass index （BMI） was revealed, which indicated comparability among the three groups.2. The proportion of eosinophilss in peripheral blood was （3.34±2.26）%, （2.49±1.79）% and （1.81±1.22）% in allergic rhinitis, non-allergic rhinitis and normal control group （P<0.05）. Eosinophils count was （0.20±0.16）×109/L, （0.16±0.13）×109/L and （0.10±0.07）×109/L in the three respective groups （P<0.05）. The positive rate of peripheral blood eosinophil count was 17.79%, 14.06% and 1.96% （P<0.01）, respectively.3. Neutrophil count in nasal lavage fluid of non-allergic rhinitis group was （48.28±141.17）/×200, which had statistical difference （P<0.05） with that of allergic rhinitis group [（13.61±46.93）/×200] and normal control group [（1.74±9.37）/×200]. Eosinophil count in nasal lavage fluid of allergic rhinitis group was （27.88±62.47）/×200, which had statistical difference （P<0.05） with that of non-allergic rhinitis group [（9.04±22.56）/×200] and normal control group [（0.76±3.46）/×200]. The positive rate of peripheral blood eosinophil count in nasal lavage fluid was 59.89%, 28.35% and 5.00% （P<0.01）, respectively.4. The proportion of eosinophil in induced sputum of allergic rhinitis group was （4.84±8.63）%, which had statistical difference （P<0.05） with that of non-allergic rhinitis group [（1.29±3.23）%] and normal control group [（0.37±0.91）%]. The positive rate of eosinophil proportion in induced sputum test was 38.32%, 13.93% and 1.42% in AR, NAR and normal control group （P<0.001）.5. Fractional exhaled nitric oxide of AR group was （25.82±18.58）ppb, which had statistical difference （P<0.05） with that of NAR group [（17.77±11.93）ppb] and normal control group [（14.15±6.79）ppb]. The positive rate was 34.07%, which had statistical difference （P<0.05） with that of NAR group and normal control group （15.15% and 6.25%, respectively）.6. No stastistical difference （P<0.05） was shown in major spirometric parameters among three groups. The sum of susceptive positive and positive rate of bronchial provocation test in AR group was 11.96%, which had significant statistical difference （P<0.01） compared with that of NAR group （2.33%） and normal control group （1.23%）.7. Two subgroups were further classified according to existence of upper airway eosinophilic inflammation in AR group, with the positive percentage rate of 48.41% and 7.50% （P<0.01） in subjects with and withour upper airway eosinophilic inflammation, respectively.8. Two subgroups were further classified according to existence of upper airway eosinophilic inflammation in NAR group, with the positive percentage rate of 26.23% and 1.69% （P<0.01） in subjects with and withour upper airway eosinophilic inflammation, respectively.9. A multiple variance Logistic regression equation of Logit（P）= -4.781+1.410X₁+2.274X₂+2.797X₃+1.134X₄ on the impact factors of eosinophils-associated inflammation was obtained, in which X₁ referred to allergen skin prick test result, X₂ was eosinophils count in peripheral blood, X₃ represented eosinophils count in nasal lavage fluid and X4 referred to bronchial provocation test result. The predisposing factors of eosinophils-associated inflammation were positive allergen skin prick test result （OR=4.096）, increased eosinophils count in peripheral blood （OR=9.715）, increased eosinophils count in nasal lavage fluid （OR=16.398） and susceptible positive bronchial provocation test result （OR=3.107）.10. A multiple variance Logistic regression equation of Logit（P）= -4.167 + 1.453X₁ + 1.587X₂ on the impact factors of airway hyperresponsiveness was obtained, in which X₁ referred to allergen skin prick test result and X₂ was the proportion of eosinophilss in induced sputum. The predisposing factors of airway hyperresponsiveness were positive allergen skin prick test result （OR=4.276） and increased eosinophils proportion in induced sputum （OR=4.890）.Conclusions1. Lower airway eosinophilsic inflammation and airway hyperresponsiveness have developed despite the absence of lower airway symptoms in a proportion of individuals with allergic rhinitis.2. Lower airway inflammatory changes have also developed despite absence of lower airway symptoms in part of subjects with non-allergic rhinitis.3. Upper airway eosinophilic inflammation was the independent predisposing factor of lower airway eosinophilic inflammation.4. Atopy and lower airway eosinophilic inflammation were independent predisposing factors of airway hyperresponsiveness. General conclusions of the study1. The method for assessment of inflammatory cell differentiation in nasal lavage fluid has been established successfully. Nasal lavage inflammatory cell absolute count is capable of offering clear discrimination between normal individuals and subjects with allergic rhinitis. Eosinophils count is the optimal positive parameter for judgment of the results of nasal lavage test, with the 95% upper reference limit of 3.47 /×200 （HE stain）.2. The prevalence rate of rhinitis reaches to 19.20%, with a similar proportion of non-allergic rhinitis and allergic rhinitis. An increase in prevalence rate of asthma in subejcts with AR and NAR has been revealed, both of which are the predisposing factors of onset of asthma.3. Lower airway eosinophilic inflammation or lower airway hyperresponsiveness has evolved in some subjects without lower airway symptoms who have allergic rhinitis or non-allergic rhinitis, which might be the early stage during progression of rhinitis to asthma.更多还原