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When you start sneezing and your nose starts running, is it allergies or a sinus infection? It can be difficult to distinguish the two, especially during the colder months. Dr. Tom Miller talks to otolaryngologist, Dr. Jeremiah Alt, about the differences between allergic rhinitis versus the common cold. Though the symptoms for both may overlap, it might surprise you that the treatments are not the same.



Allergies, colds or something else? How do you tell and how do you treat them? That's next on Scope Radio.

Access to our experts with in-depth information about the biggest health issues facing you today. The Specialists with Dr. Tom Miller is on The Scope.

Hi. I'm here with Dr. Jeremiah Alt. He is an ENT surgeon. That's an ear, nose and throat surgeon. He's a member of the Department of Surgery here at the University of Utah. Jeremiah, how does one tell the difference between an allergic symptoms of nasal discharge versus a common cold or sinusitis? Is there a way to sort of know if you have one or the other?

Yeah. That's very difficult. Even very difficult for the physician to figure that out in many cases and requires a thorough history with the patient to figure some of these things out. In general, allergic rhinitis if it's seasonal will occur during the season, where if you have hay fever, you'll get itchy eyes and a runny nose.

I always think of hay fever as being itchy.


Right? So people are scratching the corners of their eyes and they're blowing and sneezing.


The back of the throat is kind of scratchy. Sometimes when I think of the common cold or sinusitis that doesn't feel very itchy. That's [inaudible 00:01:15].

Right. So the common cold will have some of the similar symptoms, as there's definitely overlap where you can have increased congestion and nasal blockage. You'd probably be more likely, though, to have some facial pain and pressure. We commonly talk about the loss of smell occurring with sinusitis. But this can also occur with allergies as the inner lining inside your nose is swollen and angry, and inflamed and it can block off some of the ability to smell. One of the big differences though, is we commonly think of discharge. So if the discharge is yellow or green, this is more signs that this is more severe than just an allergic reaction.

More inflammation, more at that issue of infection in the sinus.


So one goes to the store to self-remedy what they would consider to be a fairly short course of this problem. If they have rhinitis, that is the itchy symptoms, what should they be using to treat that problem with? I think most of the medications now are purchased or can be purchased over the counter.

Correct. The oral antihistamines are a great option, and they've been used for many years. The second generation are non-sedating, like the Benadryls were that can make people very tired. Although, the second generations can make some people tired.

I've taken Benadryl and it works as an antihistamine. But man, does it knock me out. I think it does the same with some people and some people, they don't seem to have that fatigue that I get or that a number of people will get.


Now, I've heard with Claritin, which is an example that comes generic as loratadine, that it's not sedating. But do you think it works as well as something like Benadryl or diphenhydramine?

Well, partly it's also what we're targeting. The itchiness, I think, works great. Another great antihistamine is Zyrtec. So if the patient has the itchiness with the runny, drippy nose, what we call clear rhinorrhea, or clear, drippy nose, the Zyrtec is actually quite more drying than let's say the Claritin. So we would push the patient more towards the Zyrtec, which is a more drying medication.

This is also listed as a non-sedating antihistamine.

Correct. One thing to consider is even if the second generations make you drowsy or feel a little fatigued, you can also take them at night which is an option.

So sleep a little better and maybe get a little bit better coverage for the allergic symptoms.

Yeah. A third option that's more recent is a topical spray antihistamine. This is not taken by the mouth and you can spray it in the nose. This type of antihistamine, I've never seen it cause drowsiness or fatigue in patients, and you can use it on contact. So if you know you're going outside you can quick spray it in your nose to reduce the antihistamine response that you have for your allergies.

So Jeremiah, does that require a prescription or is that available over the counter?

That one is still a prescription medication. So you really need to get that from you allergist or your ENT, or your primary care doctor.

Now, there's another class of medication used to treat allergic rhinitis as well, and that would be the nasal steroids.

Yeah. So the nasal steroids actually have great evidence to be used both for allergic rhinitis and for many of the diseases that we talked about in some of the other podcasts, including chronic rhinosinusitis or reoccurring acute rhinosinusitis, where there's just an overall inflammation inside the sinonasal cavity. This just calms the inside of the nose down. It's a topical steroid. It's sprayed within the nose, usually dosed once or twice a day. What I like to think of it, it addresses the root of the problem.

The inflammation.

The inflammation, correct. So it really reduces the overall amount of goblet cells in the nose, the inflammatory, or those mediators in the nose and the immune system that are really creating the immune system to start with to create this inflammation.

Now, do you think that a patient with allergic rhinitis could also take the antihistamine orally, antihistamine nasal spray, and a topical steroid nasal spray, or should they use them separately? What's your thought on that?

It really depends on the patient's response and the overall diagnosis that you've come up with your doctor and your treatment plan. However, commonly we like to use both and we feel like patients get a good response by both blocking with an antihistamine and using a topical nasal steroid like Flonase or Nasonex.

Both of which they could get over the counter.


It's possible that they could start their own treatment and then if things weren't going well they could end up seeing their physician.

There is a new medication, Dymista, that has actually combined the two together. So you can get it in a single spray, which patients are noting that they've really enjoyed using just one medication instead of two separate.

Now, let's say they have the common cold or sinusitis. Do the same medications work?

Yes. In general, though, we don't typically use antihistamines for chronic sinusitis unless they have a comorbidity or that's one other disease process that they also have on top of the chronic sinusitis that we want to help control symptomology. So if they have allergies and we want to help control some of that drippy nose, postnasal drip symptoms, we can add on an antihistamine. But, yeah, the steroids are great, as we talked about. It's really disease of inflammation, so that topical nasal steroid is ideal for helping.

Would you recommend using an oral, what we call, sympathomimetic, like pseudoephedrine or Sudafed for someone who has the common cold or sinusitis?

Those are really two different diseases and two different applications for that. For an acute onset cold or viral rhinosinusitis or bacterial, this can help make the patient feel better. I don't think it really helps get you over the illness quicker. But it can help improve your overall well-being. Now, in sinusitis it can also improve your overall feel of increasing your ability to breathe through your nose. But this doesn't get at the root of the cause of the disease itself, and we commonly don't like to think of using these long-term in a disease like chronic rhinosinusitis, which is a chronic condition. You'd have to use this over potentially months and years, which we're concerned about the possibility of hypertension.

Now, you could also use the same medication as the nasal spray for a few days, I understand.

Afrin or over-the-counter oxymetazoline is a great sympathomimetic, which really reduces the overall swelling inside the nose. We commonly like to really counsel the patient that these are great short-term. So these are two to three-day treatment options, and then they really need to consider trying to come off of them.

So to wrap up, it sounds like if one has allergic rhinitis the bottom line there would be to use antihistamines orally and perhaps nasally, and also to use nasal steroids to reduce the inflammation. But when you have the common cold or sinusitis you could use an oral agent that is a medicine like pseudoephedrine or Sudafed. Or you could also use a similar compound as a nasal spray that would come as oxymetolazone [SP] or a similar compound. Then, you could also use the nasal steroids to reduce the inflammation for a short course.

TheScopeRadio.com is University of Utah Health Sciences Radio. If you like what you heard, be sure to get our latest content by following us on Facebook. Just click on the Facebook icon at TheScopeRadio.com.

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All we did was write a class specific to this test called FooTestDouble . In that class we override the protected RenderView method and set a property with the passed in argument. Then in our test, we can simply check that the argument matches our expectation (and we get a human friendly assert message to boot).

Interestingly enough, I have shown this technique to some developers who told me it made them feel dirty (I’m not naming names). They didn’t feel this was a valid way to write a unit test. One complaint is that one shouldn’t have to inherit from a class in order to test that class.

So far, none of these complaints have provided empirical reasons behind this feeling that it is wrong. One complaint I’ve heard is that we are not testing the class, we are testing a derived class.

Sure, we’re technically testing a subclass and not the class itself, but we are in control of the subclass. We know that the behavior of the subclass is exactly the same except for what we chose to override.

Not only that, the same argument could be applied to using a partial mock. After all, what is the mocking example (which many feel is more appropriate) doing but implicitly generating a class that inherits from the class being tested whereas this pattern explicitly inherits from the class.

My own feeling on this is - I want to choose the technique that involves less code and is more understandable for any given situation. In some cases, using a mock framework does this. For example, in the first case when RenderView is public, I like having my test fully self-contained. But in the second case, RenderView is protected, I think the test-specific subclass is perfectly valid. The test-specific subclass is also great for those who are not familiar with a mock framework.

While some guidelines around TDD and unit testing are designed to produce better tests (for example, the Red Green approach and trying not to touch external resources such as the database) and better design, I don’t like to subscribe to arbitrary rules that only make writing tests harder and don’t seem to provide any measurable benefit based on some vague feeling of dirtiness.

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Can you explain what you mean by VerifyAll not having a message?

I mean I can't specify my own assert message. If the expectations are not met, VerifyAll throws an exception, which provides a lot of information, but for the sake of my unit test, I may want to specify a message like I would with Assert.

Feathers calls this technique "subclass and override" in his Legacy Code book, but it's the same thing. This is a very common technique when dealing with legacy code, and I have to do this a lot with non-virtual members too ( http://grabbagoft.blogspot.... .I don't feel dirty if I'm already swimming in mud.

You can specify your desired "assert" message on each Expect.Call. So using your example, it would look like this:Expect.Call(delegate { fooMock.RenderView("it matches?"); }).Message("Did render the right view.");

The way you're using the Test-Specific Subclass is as a Stub (state-based). To me, a partial mock (interaction-based) also qualifies as Test-Specific Subclass. In the Ben Pryor post that you linked to from here , he says "A stub is a trivial implementation of an interface that exists for the purpose of collecting state during a unit test." Since as you mentioned you prefer state-based testing over Interaction-based testing, a Stub (state-based) would feel more natural to use than a Mock (interaction-based).In the case of your controller, the essence of your test is the controller's interaction with its view, so I would argue that interaction-based testing is more appropriate. You can simulate interaction-based testing with a Stub, but it has the disadvantage of jumping through the extra hoops of explicit state accumulation and retrieval/verification rather than just directly expressing the expected behavior.

Isn't this really just telling us that Controller should not have a RenderView method?

@Oran re: Message, Oh! I did not know that. Thanks!@Aaron what should it have instead?

I use this way of performing unit tests pretty often. Namely while testing repositories that need a specific nhibernate session injected. During my test fixture setup I create a sqlce session and then derive from my repositories so I can set the session with my sqlce session instead of the configuration file session.Another pattern that is better equiped for testing static/singleton objects Hammett has described here: Pants for Men On Sale navy Cotton 2017 30 32 33 34 36 38 Entre Amis Cheap Comfortable In China For Sale Excellent qY8Ln3C7m
All this is doing is just wrapping the behavior inside of another class with an interface. Then you can mock out the interface at runtime. The benefit here is that you have taken something that could not be tested and wrapper it with an interface you control and thus can be mocked!This can be used in any scenario including the one you describe above. The side effect is that it does create more code but in certain scenarios it is justified. I weigh each option closely and then make a decision on what would best serve my context. It is not often that I use the code hammett described there but sometimes it does come in useful.

I meant to comment about this before and never got around to it. You are one of the most diligent TDD devs that I know in the .NET world. A place where a lot of people don't even know where to start with TDD. Which TDD framework should I use.... how do I deal with data or databases. Are there different ways to address some core problems. Should I write a test first? etc etc etc. Can I recommend that time permitting you write down your own experience in a how-to series. I think it would be tremendously useful to a lot of people and really draws on one of your strengths.

Re: RenderView()I have to agree with Aaron. I am pretty new to the MVC concept but after doing a lot of studying, I am getting a waft of something that seems wrong from both Microsoft's MVC and the much lauded MonoRail.Microsoft's MVC(going off ScottGu's blog posts of it and the few other that are out there) seems to fall apart after the first level of Controller-View. What I mean is that after the URL is routed to the appropriate controller and action, the only thing you seem to be able to do is call a single View, with RenderView(). What about View re-use? Nesting Views? Microsoft's MVC seems, kind of like the CodeIgniter project for PHP, that a controller action has to know everything about what a View requires from the Model so that it can be displayed properly. If you want to re-use a View inside another Controller, it seems that you have to duplicate the means of getting the data into all the Views that you are displaying from that new Action.MonoRail has something called a ViewComponent to alleviate this but even from their own documentation, ViewComponent smells like a duplication of their Controller class.It all boils down to appearing to me that both of these frameworks require the Controller to pass the data from the Model to the View, rather than the View just grabbing it straight from the Model. There is nothing in the MVC pattern(that I am aware of) that prohibits the View from doing this either.Maybe I am just misunderstanding something crucial here though and would love to be corrected.

@Thomas Thanks for the suggestion. I've written a lot on the topic. I'll try to categorize what I've written and shore up areas that I haven't covered.@Ted> What about View re-use? Nesting Views?You can encapsulate views in user controls. Works great. You can call RenderView and specify a user control instead of a full page.Master pages still work, which is one form of nesting views.However, the thing you're probably referring to is how do we handle sub-controllers. That's not addressed in the upcoming CTP, but we are investigating multiple solutions.

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The project I'm currently working on at my company uses custom app blocks to implement the provider model. We've got about seven different providers from logging to state machine. I've created mock implementations for many of them. Its a very convenient way to test objects that rely on the blocks. Set the MockDatabase.ThrowException, call your method, and assert on MockLog.LastErrorMessage. Yes, its extra code, but its incredibly simple code.

> @Aaron what should it have instead?A service with a RenderView method on it. Right now RenderView invokes the ViewFactory to Create the view and then calls RenderView on that view. It's nothing more than a helper method, but perhaps its a method that should be on an IViewRenderer? MS is making the same mistake MR made in putting way too much functionality on the controller. That said, with no changes to the framework, couldn't you just mock the IViewFactory to return a mock view and not have to do any of the awkward self-mocking/subclassing nonsense? Of course without reflector you wouldn't know you could do this... which just goes to show the flaw in the design.

@Aaron Ah! I see what you're saying. So it seems to me that you're suggesting we put another service in between Controller and IViewFactory. Is that right?Yes, I could have mocked IViewFactory, but after the IView is returned from the factory, the RenderView method also creates a ViewContext which is passed to the view when rendering which requires other dependencies I need to mock.It ends up being seriously less code than just overriding RenderView. Perhaps that's a code smell. Perhaps it's saying I should just override RenderView and go home. ;)Once the bits are out, I'd love to hear about your TDD experience and see how we can improve it.

Writing Unit Tests For Controller Actions

Very interesting, I recently wrote a blog post about how to test private methods on abstract classes using a combination of Partial Mocks, and the dubious MS Private accessors. buckled short skirt Blue OLYMPIAH Footlocker Online Free Shipping Sale Very Cheap Pre Order Cheap Sale Manchester rql1aeJr
Where possible I avoid doing "test specific subclass" as I just find it really unreadable, and I find it hard to concentrate on which methods I am testing and which ones I'm overriding etc. Partial mocks (in general) lead to better readability IMO.

I guess really it depends on how "dirty" one feels about the alternatives to Test Specific Subclasses in the protected method case. You could always leave it untested !;)Being a novice and all, here's what I feel about this testable class creation right off the bat:Partial mocks = automated = goodTest Specific Subclasses = manual = badYes, it's an oversimplification, but put it this way: why do you prefer "having my test fully self-contained" if you're not having the same "dirty" feeling that these other devs are expressing? Maybe you're just less sensitive to the dirt?

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