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Atopic dermatitis (AD) is one of the main risk factors for infants in the development of food allergy. Oral immunotherapy (OIT) in early childhood has been found to be highly effective and safe in preschoolers with and without AD, especially in young infants. Delays in initiation of OIT in infants and children due to uncontrolled AD risk expansion of the number of foods children develop allergy to through unnecessary avoidance of multiple foods. Parents and caregivers may attribute eczema flares to OIT doses, which physicians usually ascribe to non-food triggers such as weather changes, psychological stress, and infection. There is a lack of published literature confirming OIT as a trigger of AD flares, and the degree to which OIT may be associated with AD flares needs to be further studied. We describe 8 case scenarios with varying degrees of AD flare before and during OIT. We propose management algorithms for children with preexisting concurrent AD and food allergy who are being considered for starting OIT and children with AD flares during OIT. Optimizing AD control strategies and providing adequate AD care education before starting OIT can reduce confusion for both parents and allergists if rashes arise during OIT, thus improving adherence to OIT., Competing Interests: Disclosures Dr Chua received honorarium from Pharmaniaga, Sanofi, and Menarini and is an advisory board member on maternal immunization against respiratory syncytial virus of Pfizer. Dr Mack has provided consultation and speaker services for DBV, ALK, and Alladapt and is an investigator for DBV, ALK-Abello, Dermavant, Arcutis, and Amgen. Dr Shaker is a member of the Joint Task Force on Practice Parameters, serves on the editorial board of the Journal of Allergy and Clinical Immunology In Practice, is an associate editor of Annals of Allergy, Asthma, and Immunology, and serves on the Board of Directors of the American Academy of Allergy, Asthma, and Immunology (views expressed are his own). Dr Chan has received research support from DBV Technologies; has been a member of advisory boards for Pfizer, Miravo, Medexus, Leo Pharma, Kaleo, DBV, AllerGenis, Sanofi Genzyme, Bausch Health, Avir Pharma, AstraZeneca, ALK, and Alladapt; and was co-lead of the CSACI oral immunotherapy guidelines., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Adverse events occur in all fields of medicine, including allergy-immunology, in which allergen immunotherapy medical errors can cause significant harm. Although difficult to experience, such errors constitute opportunities for improvement. Identifying system vulnerabilities can allow resolution of latent errors before they become active problems. We review key aspects and frameworks of the medical error response, acknowledging the fundamental responsibility of clinical teams to learn from harm. Adverse event response comprises 4 major phases: (1) event recognition and reporting, (2) investigation (for which root cause analysis can be helpful), (3) improvement (inclusive of the plan-do-study-act cycle), and (4) communication and resolution. Throughout the process, clinician wellness must be maintained. Adverse event prevention should be prioritized, and a human factors engineering approach can be useful. Quality improvement tools and approaches complement one another and together offer a meaningful avenue for error recovery and prevention., Competing Interests: Disclosures Dr Bansal serves on the board of directors of the American Academy of Allergy, Asthma and Immunology and American Board of Allergy and Immunology (views expressed are her own). She has participated in advisory boards and served as a speaker for ALK, AstraZeneca, Bryn, Sanofi Genzyme/Regeneron, Takeda, CSL, Pharming, and Glaxo Smith Kline. Dr Shaker is a member and cochair of the Joint Task Force on Practice Parameters, serves on the editorial board of The Journal of Allergy and Clinical Immunology In Practice, is an associate editor of Annals of Allergy, Asthma & Immunology, serves on the board of directors of the American Academy of Allergy, Asthma, and Immunology (views expressed are his own), and has participated in research that has received funding from DBV. Dr Bradley is the director of Graduate Medical Education Quality and Safety, Dartmouth Health. The remaining authors have no conflicts of interest to report., (Copyright © 2024 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Allergen immunotherapy (AIT) is safe and effective but is typically administered under strict clinic observation to mitigate the risk of a systemic reaction to immunotherapy (SRIT). However, in the setting of the global coronavirus disease 2019 pandemic, alternative care models should be explored., Objective: To evaluate the cost-effectiveness of home immunotherapy self-administration (HITSA) in a highly idealized circumstance for provision of maintenance AIT in a shelter-in-place or other scenarios of unforeseen reduction in nonessential medical services., Methods: Markov modeling was used to compare in-office clinic AIT in selected patients using cohort analysis and microsimulation from the societal and health care perspectives., Results: Assuming similar SRIT rates, HITSA was found to be a cost-effective option with an incremental cost-effectiveness ratio of $44,554/quality-adjusted life-year when considering both incremental epinephrine autoinjector costs and coronavirus disease 2019 risks. Excluding epinephrine autoinjector costs, HISTA dominated other options. However, outside of pandemic considerations, HITSA was not cost-effective (incremental cost-effectiveness ratio, $198,877,286) at annual epinephrine autoinjector costs above $287. As the incremental HITSA SRIT rate increased above 15%, clinic AIT was the most cost-effective strategy. Excluding both pandemic risks and risk of motor vehicle accident fatality from round-trip clinic transit, clinic AIT dominated other strategies. Clinic AIT was the more cost-effective option at very high fatality relative risk for HITSA or at very low annual risk of contracting coronavirus disease 2019., Conclusions: Under idealized assumptions HITSA can be a safe and cost-effective option during a global pandemic in appropriately selected patients provided home rates of SRIT remain stable., (Copyright © 2020. Published by Elsevier Inc.)

Anaphylaxis is an acute, potential life-threatening systemic allergic reaction that may have a wide range of clinical manifestations. Severe anaphylaxis and/or the need for repeated doses of epinephrine to treat anaphylaxis are risk factors for biphasic anaphylaxis. Antihistamines and/or glucocorticoids are not reliable interventions to prevent biphasic anaphylaxis, although evidence supports a role for antihistamine and/or glucocorticoid premedication in specific chemotherapy protocols and rush aeroallergen immunotherapy. Evidence is lacking to support the role of antihistamines and/or glucocorticoid routine premedication in patients receiving low- or iso-osmolar contrast material to prevent recurrent radiocontrast media anaphylaxis. Epinephrine is the first-line pharmacotherapy for uniphasic and/or biphasic anaphylaxis. After diagnosis and treatment of anaphylaxis, all patients should be kept under observation until symptoms have fully resolved. All patients with anaphylaxis should receive education on anaphylaxis and risk of recurrence, trigger avoidance, self-injectable epinephrine education, referral to an allergist, and be educated about thresholds for further care., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Peanut oral immunotherapy (POIT) decreases the probability of accidental recurrent systemic reactions but reactions from the therapy itself are frequent., Objective: The purpose of this economic analysis was to characterize the potential cost-effectiveness of POIT., Methods: Cohort simulations were used to evaluate the effect of POIT for children with peanut allergy. A POIT with probiotic was used in the base-case simulation and long-term survival was modeled using age-adjusted mortality together with the risk of food allergy-associated mortality., Results: The incremental POIT cost-effectiveness ratio was $2142 per quality-adjusted life-year. A mean number of 12.3 (95% CI, 12.0-12.5) and 2.0 (95% CI, 1.9-2.1) allergic reactions occurred in the POIT and avoidance groups over 20 years of simulation, with 2.3 (95% CI, 2.2-2.3) episodes of anaphylaxis treated with intramuscular epinephrine per subject in the POIT group and 1.1 (95% CI, 1.0-1.2) episodes per subject in the avoidance group. In sensitivity analyses, POIT was associated with lower rates of anaphylaxis than strict avoidance when the annual rate of accidental allergic reactions in the peanut avoidance group exceeded 25%, the annual rate of anaphylaxis in the POIT group dropped below 6%, or the probability of sustained unresponsiveness after 4 years of POIT was 68% or greater., Conclusions: POIT may be cost-effective in a long-term economic model. However, treated patients may experience a greater rate of peanut-associated allergic reactions and anaphylaxis. The analysis was sensitive to rates of accidental allergic reactions, therapy-associated adverse events, and likelihood of therapy-induced tolerance., (Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Allergic reactions to stinging insects may be unexpected, frightening, and severe. A clear understanding of recent advances in the field facilitates appropriate care of children who experience severe reactions to hymenoptera stings., Recent Findings: Recent investigations have underscored the importance of appropriate patient selection for potentially life-saving venom immunotherapy. Venom immunotherapy is effective in preventing future anaphylaxis from hymenoptera stings. Immunotherapy is indicated for patients with a history of anaphylaxis. Children who develop large local swelling or strictly cutaneous systemic reactions generally do not require immunotherapy. Component resolved diagnostic testing has been investigated to clarify the possibility of multiple venom allergies in patients with sensitization to multiple venoms., Summary: Rapid recognition and treatment of anaphylaxis are critical. Subsequent education about avoiding future stings and attention to emergency preparedness with appropriate prescription of self-injectable epinephrine is important. Referral of patients who have experienced venom-associated anaphylaxis for possible venom immunotherapy can prevent future severe episodes of anaphylaxis resulting from stings.