Dominique Joyal, MD

• Interventional Cardiology Fellow
• Cardiology Division
• Loyola University Medical Center
• Maywood, Illinois

On September 18 allergy quick fix order 50 mcg flonase overnight delivery, 1926 allergy shots zyrtec generic 50 mcg flonase with amex, a Category 4 storm ripped across Florida and caused the waters of Lake Okeechobee to wash over the dike near Moore Haven allergy quotes funny discount 50mcg flonase with amex, killing at least 150 to 300 people allergy shots unitedhealthcare discount 50 mcg flonase with visa. Just two years later, before any preventive measures were taken, an even fiercer storm, the 1928 Hurricane, crossed the lake causing devastating damage and massive fatalities. When the storm hit the lake, a small dike at the south shore of the lake was breached. Many houses were knocked off of their foundations and broke into pieces against any obstacle that they floated into. Post Disaster Redevelopment Plan Volume 2 89 who lived around the lake) although the actual number was considered by some witnesses to be much higher. The vast majority of deaths were the direct result of the flooding of Lake Okeechobee, not the winds. The area was impacted once again in 1947 by two hurricanes, which caused flooding on the south side of the lake. Lauderdale hurricane, the "Central and South Florida Flood Control Project" was created to build extra canals and levees. Under the auspices of the new management, the Herbert Hoover Dike was built around the full circumference of the lake. Near Failures In late summer and early fall of 1995 extreme rain caused Lake Okeechobee to rise to an elevation of 18. The impacted areas, ranging in length from a hundred feet to over a mile, included locations near Lake Harbor, Pahokee, and Belle Glade. Both of those events produced observable evidence of piping, berm collapses, excessive seepage, boils, and sinkholes in the embankment crest. District engineers performed a detailed inspection of 84 miles of the dike from Port Mayaca to Moore Haven. During the inspection, several distressed areas were identified that were seeping turbid water, suggesting significant piping. The following year, Hurricane Wilma caused erosion of the dike near the Pahokee municipal airport. Likelihood of Future Occurrences An independent Expert Review Panel Report commissioned by the South Florida Water Management District warned that there is a high likelihood of a dike failure. They suggested this likelihood is strongly correlated with the amount of water in the lake. The report notes that recent tropical storm and rain events which caused the lake levels to rise significantly took their toll on the dike in the form of seepage, piping and internal erosion. Post Disaster Redevelopment Plan Volume 2 90 failure will continue, if not increase. The current trend of above average numbers of intense landfalling hurricanes and tropical storms is expected to continue for several more years. The time required for a long-term fix (re-evaluation, redesign, land acquisition, and reconstruction) is estimated to be more than 25 years. The prospect of a failure before long-term fixes can be put in place is a major concern. Army Corps of Engineers recently sought independent professional opinions and carried out their own probabilistic assessments. They concluded that without intervention, the probability of a dike failure is approximately 1 in 6 in any given year. The Expert Review Panel believes that the number of years of service life remaining in the current dike without rehabilitation is totally dependent on the occurrence of higher lake levels. However, given the limited capacity for lowering lake levels quickly, sustained lake levels above this threshold can reasonably be anticipated within a 10-year period. Presently, with maximum outflow, the lake can be lowered a maximum of one tenth (. While elevated lake levels may not be immediately catastrophic, rapid emergency intervention will be required to prevent breaches. A breach of some magnitude is considered highly probable if the lake remains at or above 20 feet for an extended length of time (approximately an 80-year occurrence). During the harvest season, as many as 4,500 additional seasonal migrant workers take up temporary residence in the area. There could be far-reaching effects throughout southern Florida should the Herbert Hoover Dike fail. Beyond the 40,000 plus residents whose houses and lives would be in immediate danger, 5 million people reside in areas south of the lake could also be at risk. Saunders describes an alarming worst case scenario where flood damages could be 10 times that of Katrina and deaths reaching 100,000. Post Disaster Redevelopment Plan Volume 2 91 At this writing, lake levels are currently low and the breach threat is temporarily out of the spot light. However, one wet tropical storm could potentially lead to a breach, flooding thousands of square miles around and south of the lake as far as Miami. A catastrophic breach could sever essential road, rail, power and communications to five million people for months. The portion of the dike that is at greatest risk is "directed" at West Palm Beach, in the heart of the county. The report from the Expert Review Panel points out that "Without Lake Okeechobee there would be no Everglades. Cyclonic energy (hurricane frequency and storm intensity) and levee/dike failure were primary determinants of vulnerability. Physical factors included storm surge and freshwater flooding potential as well as coastal erosion trends and island breaching history. New Orleans, Louisiana Lake Okeechobee, Florida Florida Keys Coastal Mississippi Miami/Ft. Petersburg, Florida 92 the results of a comprehensive risk and vulnerability assessment based on a theoretical "worst case" dike breach scenario were presented in a document entitled Hurricane Ono Consequence Projection published by the multi-agency Florida Catastrophic Planning Project team in June of 2007. Modeled on the 1928 Okeechobee hurricane, the study concluded that virtually the entire region south of Martin County could be impacted by a combination of surge, wind and rain effects. Preparation, response, and evacuation would be complicated and strained by the fact that much of the local population has special needs in terms of language isolation, lack of car ownership, housing, employment status, immigration status, etc. While repairs and upgrades to the dike are already underway, it is estimated the project will take at least 25 years to complete. The main products of the Florida Catastrophic Planning project will be comprehensive Emergency Management Plan annexes and supporting plans that can be implemented in the interim. Post Disaster Redevelopment Plan Volume 2 93 Corps Rehabilitation Initiatives the U. Army Corps of Engineers has initiated comprehensive engineering initiatives to mitigate future dike breach flooding disasters. Beginning with the most problematic areas of the dike first; they examined several engineering alternatives to reduce the possibility of a breach in Reach 1. The preferred alternative includes the construction of an impervious cutoff wall at the crest of the dike and a stability seepage berm. The preferred alternative design is believed to offer the best technology available to reduce seepage and piping immediately at the most critical areas of the dike as well as to offer improved stability and protection in the long-term. As part of the new design, a berm (a shelf or raised barrier) will be built to decrease erosion and the cutoff wall will be built deeper and in the middle of the dike. Lowering lake level in hurricane season: Lake Okeechobee was lowered to an acceptable lake elevation for the beginning of the 2006 hurricane season. Army Corps of Engineers will continue to use its current authority to maintain the lake elevation at safe levels going into future hurricane seasons. Further, we are in the process of studying the possibility of revising the approved lake regulation schedule to allow us to manage the lake at a lower average level year-round, to balance estuary health, a viable lake ecosystem and water supply. We will continue to coordinate with Florida Power & Light and with the South Florida Water Management District to remove and relocate power poles constructed on the dike and within the Herbert Hoover Dike right of way. We share your goal to have all power poles relocated off Herbert Hoover Dike project limits. Army Corps of Engineers has a rigorous inspection program, the frequency of which (from once every ninety days to daily) corresponds to lake pool elevations. Potentially vulnerable areas are identified through these inspections and additional monitoring takes place, even at lower lake elevations, as necessary. Materials, equipment and personnel for emergency repairs: Just as the Corps prepared for Hurricane Wilma and previous storms, it will continue to provide all necessary materials, equipment and personnel to ensure that any identified vulnerabilities in the Herbert Hoover Dike are quickly and effectively repaired. It has stocked supplies at various locations around the Herbert Hoover Dike, and will preposition equipment prior to predicted storms, to allow immediate access and ready availability in the event a repair is necessary. Acceleration of repairs and rehabilitation: Erosion containment repairs and debris removal that were required as a result of the 2005 hurricanes were completed.

On physical examination allergy asthma and sinus center buy cheap flonase 50mcg on line, a retractile testis will be palpable outside the external inguinal ring and can be gently manipulated into the scrotum by overcoming the cremasteric reflex allergy forecast new orleans generic 50mcg flonase free shipping. Ultrasonography does not reliably distinguish an undescended from retractile testis allergy forecast granbury tx 50 mcg flonase sale. Testes that remain in the inguinal canal are at greater risk for injury from blunt trauma because they can be compressed against the pubic bone allergy medicine and mucinex order flonase 50mcg online. The contralateral descended testis is also at risk for germ cell loss, infertility, and malignancy. Bilateral involvement and increased duration of suprascrotal location of the testis increase the degree of germ cell dysfunction. Hence, orchiopexy before age 1 year is preferred, with the ideal time being as soon as possible after 6 months of age. Surgical repositioning of the testis before puberty decreases the risk of testicular cancer, but does not completely eliminate it. He specifically denies any history of hematuria, hematochezia, epistaxis, or unusual bruising. A complete evaluation for iron deficiency includes a serum iron level, total iron binding capacity, reticulocyte count, and a ferritin level. The 2 primary components of hemoglobin that can be deficient are iron (deficiency of which causes decreased heme production) or the globin protein. Hemoglobin A, the normal adult hemoglobin variant, consists of 2 Я- and 2 a-globin chains, with the Я-globin gene located on chromosome 11 and the a-globin gene on chromosome 16. Mutations resulting in reduced production of either a- globin or Яglobin result in various thalassemia phenotypes, and present with a microcytic anemia. In order to form hemoglobin, the 4 globin subunits must bind to a molecule of heme, which is dependent on iron. Although the patient in the vignette could theoretically have a variant of thalassemia, his acute findings are more consistent with iron deficiency. The human body has a tight regulatory system for the absorption of iron, but no mechanism of iron excretion. It would be highly unusual for a male adolescent with a relatively normal diet to develop iron deficiency from dietary restriction. It is therefore very important that any time a male adolescent presents with iron deficiency anemia, a source of iron loss must be sought. Causes of iron loss in this population would include gastrointestinal bleeding, paroxysmal nocturnal hemoglobinuria, and pulmonary hemosiderosis. Paroxysmal nocturnal hemoglobinuria can be evaluated through flow cytometry on a blood sample, and pulmonary hemosiderosis can be initially screened through a chest radiograph. If suspicion of hemosiderosis is strong, sputum analysis for hemosiderin-laden macrophages is recommended. While all 3 should be evaluated in the patient in the vignette, the most common cause would be gastrointestinal bleeding. Iron therapy for iron deficiency should include 2 mg to 4 mg of elemental iron per kg of weight daily. For the patient in the vignette, the most appropriate dose of elemental iron would be 120 mg to 240 mg daily, which would be 600 mg to 1,200 mg of iron sulfate daily. The high concentration of casein and whey proteins in milk inhibits iron absorption, and tea contains chelators that will bind the iron and prevent its absorption. Medications that decrease the acidic environment of the upper gastrointestinal tract may also impair absorption of iron. She has periodically missed school over the past year when she had physical complaints or reported having severe anxious feelings before school. This has worsened recently over the past week with complaints of headache, stomachache, and anxiety before school each morning, causing her to miss school each day. The mother notes that these complaints are relieved when she stays at home by herself or when she goes to work with her mother. She has been a good student, except for missing assignments when she is absent from school. The adolescent in this vignette might have a separation anxiety disorder (given her history of being "clingy" with mom), or she might have a somatic symptom disorder. Her history of experiencing headaches and stomach aches right before going to school, which are then relieved as she avoids school, is a typical way for anxiety to manifest as physical symptoms. Separation anxiety disorder is a developmentally inappropriate and excessive anxiety about separating from home or from an individual with a persistence beyond 4 weeks. While as many as half of early school age children demonstrate some separation anxiety symptoms, only about 4% develop a level of dysfunction consistent with a separation anxiety disorder. There are both genetic and social origins for the development of separation anxiety disorder. There may be an inborn low threshold for experiencing anxiety that enables not just the appearance of separation anxiety disorder, but also other anxiety disorders like generalized anxiety disorder and social phobia. Even in the absence of any particular genetic predisposition for experiencing anxiety, highly anxious parenting may teach children to adopt a fearful view of their world. School avoidance can be a major problem when it occurs because it typically becomes increasingly difficult to resolve the longer the child remains out of school. One reason why prolonged avoidance is such a problem is that our brains interpret anxiety relief from avoidance as proof that a fear was well founded, and thus future anxious reactions to the same situation deepen. For children avoiding school, this means that their fears about school usually increase the longer their duration of avoidance, and it becomes more and more difficult to get them to return. The hallmark of an effective school avoidance intervention involves getting the child back into school immediately without their parent sitting next to them. Supports of many forms can be provided as appropriate while the child is at school, such as homework or class work modifications, a plan for how the child will receive support by school staff, schedule modifications, etc. If any persisting anxiety is present, enrollment in psychotherapy would be appropriate. If the trigger for the avoidance was a truly aversive situation such as school bullying, then that will need to be addressed. Temporary home tutoring is counter productive for anxiety driven school avoidance because it makes it easier for the child and family to avoid a return to school. Arranging for a parent to remain in the classroom is a strategy that parents might request for a young child with separation anxiety, but this is likely to only delay the separation crisis, as it nonverbally communicates to the child that they cannot handle the situation on their own, and it is distracting to child and classroom function while the parent is present. A single separation at the start of school is usually easier on both parents and children in this situation. An unaccompanied return to school as soon as possible is needed for these children. Her mother states that she was ill with a diarrheal illness 2 weeks ago and has been tired since that time, but became acutely ill and drowsy today. Her heart rate is 180 beats/min, her respiratory rate is 40 breaths/min, and her breathing is shallow. Her cardiac examination is significant for a difficult to palpate point of maximal impulse that is displaced to the left and weak. You appreciate S1 and S2 and hear a third heart sound in early diastole but no murmur. You are planning admission to the intensive care unit and getting consultations arranged. You place the child on 100% oxygen by non-rebreather mask and establish intravenous access. Her systemic output is very poor and additional support may well be required in this child. Careful monitoring needs to be maintained when dopamine is used because although it may improve function, it may also stimulate atrial or ventricular arrhythmias. Soon after initiation of inotropic support, antiarrhythmics would be indicated, especially if any further ectopy was noted. Lidocaine is a good option for ventricular ectopy in this setting, as there is less risk of hypotension. Ventricular arrhythmias are most common, but there is also risk of atrioventricular block. Diagnostic evaluation is directed towards assessment of the degree of cardiac failure and impending respiratory failure, as well as determining the underlying etiology. Intensive care will be needed to monitor for development of ventricular arrhythmia or heart block. An echocardiogram will be needed to assess the degree of systolic ventricular dysfunction and chamber size.

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In mild cases this worsening can usually be managed with cholinesterase inhibitors allergy free dog food discount flonase 50 mcg overnight delivery. In patients with oropharyngeal or respiratory involvement allergy testing jacksonville nc order flonase 50 mcg otc, we perform plasma exchange before beginning prednisone to prevent or reduce the severity of corticosteroid induced exacerbations and to produce a more rapid response allergy treatment in infants discount 50 mcg flonase with mastercard. Once improvement begins allergy austin buy flonase 50 mcg online, subsequent corticosteroid-induced exacerbations are unusual. An alternative approach favored by some is to begin prednisone with 20 mg/day and increase the dose by 10 mg every 1 Physician Issues to 2 weeks until improvement begins. Exacerbations still may occur with this protocol but the onset of such worsening and the therapeutic response are less predictable. Hypercorticism occurs in approximately onehalf the patients treated with high doses. The severity and frequency of side effects increase when high doses are continued for more than one month. Fortunately, this is rarely necessary, especially if plasma exchange is begun at the same time as prednisone. Most side effects improve as the dose is reduced and become minimal at less than 20 mg every other day. Side effects can be minimized by a low-fat, low-sodium diet and supplemental calcium. Postmenopausal women should also take supplementary vitamin D or a bisphosphonate. Prednisone given with azathioprine, cyclosporine, mycophenolate or other immunosuppressant drugs may produce more benefit than either drug alone (see next section, Immunomodulatory Drugs). It improves weakness in most patients but benefit may not be apparent for 4 to 8 months. The initial dose is 50 mg/day, which is increased 50 mg/day every 7 days to a total of 150 to 200 mg/day. Improvement persists as long as the drug is given but symptoms almost always recur if it is discontinued or the dose is reduced below the minimal effective dose. Patients may respond better and more rapidly if prednisone is started at the same time. The prednisone is tapered as above and may be discontinued after azathioprine becomes effective. A prospective randomized study showed that the addition of azathioprine to prednisolone significantly reduced the dose of prednisolone required to maintain remission and reduced the number of treatment failures (Palace J, 1998). An idiosyncratic reaction, with "flu-like" symptoms occurs within 10 to 14 days after starting azathioprine in 15% to 20% of patients; this reaction requires that the drug be stopped. Gastrointestinal irritation can be minimized by using divided doses after meals or by dose reduction. Leukopenia and even pancytopenia can occur at any time during treatment, but are not common. Less common: hepatic toxicity, leukopenia Common: renal toxicity hypertension, multiple potential drug interactions Common: leukopenia, hair loss, cystitis Common: diarrhea, mild leukopenia Azathioprine 4 to 8 months Cyclosporine A 2 to 3 months Cyclophosphmide variable Mycophenolate mofetil 2 to 4 months (? To prevent liver toxicity treatment should be discontinued if transaminase concentrations exceed twice the upper limit of normal and restart the drug at lower doses after values become normal. Rare cases of azathioprine-induced 36 pancreatitis are reported but the cost-effectiveness of monitoring serum amylase concentrations is not established. This complex of cyclosporine and cyclophilin inhibits calcineurin, which activates transcription of interleukin-2. It also inhibits lymphokine production and interleukin release and leads to reduced function of effector T-cells. Serum creatinine should be measured monthly and the dose adjusted to keep the creatinine below 150% of pretreatment values. Thereafter, serum creatinine should be measured at least every 2 to 3 months and more frequently after any new medications are begun. Physician Issues Improvement begins within 2 to 3 months in most patients and maximum improvement is achieved after 6 months or longer. Cystitis, leukopenia, nausea, vomiting, anorexia and discoloration of the nails and skin occur less frequently and bladder cancer is a major concern. It also suppresses the formation of antibodies active in complement-dependent lysis and antibody-dependent, cell-mediated cytotoxicity. The most common side effect is diarrhea, which can usually be managed by altering the dose schedule. The risk of leukopenia requires 37 periodic blood counts, especially after beginning therapy. It is used as a short-term intervention for patients with sudden worsening of myasthenic symptoms for any reason, to rapidly improve strength before surgery, to prevent exacerbations induced by corticosteroids and as a chronic intermittent treatment for patients who are refractory to all other treatments. Most patients who respond to the first course respond again to subsequent courses. Repeated exchanges do not have a cumulative benefit and should not be used as chronic maintenance therapy unless other treatments have failed or are contraindicated. The major complications are related to the route of access and peripheral venipuncture should be used whenever possible. Thromboses, thrombophlebitis and subacute bacterial endocarditis, as well as pneumothorax and brachial plexus injury are risks when subclavian lines, arteriovenous shunts or grafts are placed for vascular access. The minimum dose has not been established and no prospective controlled trial has yet been reported. A single dose of 1 gm/kg has been reported to be as effective as 2 gm/kg in treating myasthenic crisis (Gajdos P, 2006). These reactions can be reduced by giving acetaminophen or aspirin with diphenhydramine before each infusion. Cerebrovascular and myocardial infarction have been reported but the mechanism for these is not known and it is unclear if they are related to the infusion rate, the immunoglobulin concentration, bystander products or the osmolality of the preparation. Pre-existing arteriosclerosis appears to be a prerequisite for the occurrence of strokes or heart attacks. Other less severe adverse events such as alopecia, aseptic meningitis, leukopenia and retinal necrosis have also been reported. Although contamination of human blood products by donors having Creutzfeldt-Jakob disease has been reported, there is no reported case of transmission of this disease by blood products. These agents carry a significant risk of arrhythmia, hypotension and pulmonary edema and should be used with great caution. Thyroid disease should be vigorously treated both hypo and hyperthyroidism adversely affect myasthenic weakness. Ophthalmic preparations of beta blockers and aminoglycoside antibiotics may cause worsening of ocular symptoms. Vaccination against pneumococcus is recommended in at-risk patients before starting prednisone or other immunosuppressive drugs. The Centers for Disease Control and Prevention reports that those taking less than 2 mg/kg per day of prednisone or everyother-day prednisone are not at risk. Immunosuppression is recommended if disabling weakness recurs or persists after thymectomy, or if there is not continual improvement 12 months after surgery (see Corticosteroids and Immunosuppressant Drugs, earlier in this chapter). If the response is unsatisfactory, we add azathioprine in patients who can tolerate the expected delay before responding. If treatment with azathioprine is unsatisfactory, prednisone is added or mycophenolate mofetil is substituted for azathioprine. Azathioprine or mycophenolate mofetil may be started at the same time and the prednisone dose reduced or even discontinued after the maximum response has been obtained. There is no standard cookbook approach and the decisions of management approach must be based upon the unique features of the patient; their degree of weakness, pattern of weakness, reliability, resources available, etc. If the response is unsatisfactory, prednisone is added, either in incrementing or high daily doses. Thymectomy may be considered in young patients when ocular weakness persists despite cholinesterase inhibitors. The development of weakness in muscles other than the ocular or periocular muscles moves paPhysician Issues 41 2.

In rare instances allergy forecast tyler tx buy flonase 50 mcg cheap, environmental regulations may prohibit removing natural debris and new growth from some drainage ways allergy symptoms to wheat buy generic flonase 50mcg on-line. Maintenance activities allergy testing frequency order 50mcg flonase overnight delivery, most commonly allergy treatment by yoga proven flonase 50 mcg, include ongoing monitoring, debris and sediment removal, and the correction of problem sites and damaged systems by field crews. Given the sheer size of the County, the vigilance of citizens is a critical element in identifying potential drainage problems. The County has ongoing programs for structural and permanent changes to channels or basins. Coastal communities commonly undertake a variety of maintenance measures including dune and mangrove preservation, bluff stabilization, and beach nourishment to protect coastal buildings, property, and coastal water bodies from flooding and erosion. The county and municipalities work continuously to improve and maintain their storm water management systems. Regulatory Measures Flood Damage Prevention Ordinances Unincorporated Palm Beach County and many of the municipalities have Flood Damage Prevention Ordinances. Proposed development must not increase flooding or create a dangerous situation during flooding, especially on neighboring properties. If a structure is involved, it must be constructed to minimize damage during flooding. Permitting officials work with applicants to discourage development in the floodplain wherever possible, but when unavoidable, the effects of development must be minimized. Post Disaster Redevelopment Plan Volume 2 74 Damage to "new" and "substantially improved" floodplain structures is minimized by elevating the lowest floor of occupied areas a specified amount above the 100-year flood elevation. Substantially improved structures are subject to the same elevation standards as new structures. Elevation Certificates To verify that buildings have been properly elevated, building officials require the completion of an Elevation Certificate by a professional engineer or surveyor. After the lowest floor is in place, its elevation above sea level is determined by a survey. The Elevation Certificate is part of the permit record and must be submitted before the building may be occupied. Structural Mitigation Measures While flood insurance can greatly reduce the cost of flood losses and rebuilding, there are six mitigation measures that can help prevent houses from flooding in the first place, even if they reside in a special flood hazard area. Particularly if a property has sustained previous flood damage or is at high risk, the following mitigation projects are recommended to homeowners as potentially good investments. Elevation Projects ­ Raising a house so that the lowest floor is above the flood level. This can be done by elevating the entire house, including the floor, or by leaving the house in its existing position and constructing a new elevated floor within the structure. The method used depends largely on construction type, foundation type, and flooding conditions. Wet Floodproofing ­ Wet floodproofing involves modifying the uninhabited portions of a house. This also allows interior and exterior hydrostatic pressures to equalize, reducing the likelihood of wall failures and structural damage. Dry Floodproofing ­ Dry floodproofing involves sealing a house to prevent flood waters from entering. Making the house watertight requires sealing the walls with waterproof coatings, impermeable membranes, or supplemental layers of masonry or concrete. Doors, windows, and other openings below flood levels must be equipped with permanent or removable shields, and backflow valves must be installed in sewer lines and drains. Construction of Levees and Floodwalls ­ Constructing flood protection barriers around the house to help hold back flood water. Levees are typically compacted earthen structures; floodwalls are engineered structures usually built of concrete, masonry, or a combination of both. Post Disaster Redevelopment Plan Volume 2 75 Relocation ­ Moving a house to high ground outside the flood hazard area is also an option. When space permits it may be possible to relocate the house to higher ground on the same piece of property. Demolition ­ Tearing down a damaged or high risk structure and either rebuilding properly somewhere on the same property or moving to property outside the regulatory floodplain. Flood insurance is designed to provide an alternative to disaster assistance to reduce the escalating costs of repairing damage to buildings and their contents caused by floods. Flood damage is reduced by nearly $1 billion a year through communities implementing sound floodplain management requirements and property owners purchasing of flood insurance. Mapping flood hazards creates broad-based awareness of flood hazards and provides the data needed for floodplain management programs and to actuarially rate new construction for flood insurance. Communities can earn points in as many as 18 different creditable activity areas grouped into four areas of emphasis: promoting public awareness, reduction of flood damage, improved mapping and regulations; and enhanced flood preparedness. Property owners residing within a Special Flood Hazard Area (an area subject to the one percent chance a year) may qualify for anywhere between a 5% and 45% discount. Property owners outside the Special Flood Hazard Area qualify for a standard discount of 5%. The collective activities of these communities produces nearly $6 million per year in insurance savings for residents on the 165,800 policies in force countywide. Second, the community can evaluate the effectiveness of its flood program against a nationally recognized benchmark. Third, technical assistance in designing and implementing some activities is available at no charge. Fourth, the flood program benefits from having an added incentive to maintain its flood programs over the years. Post Disaster Redevelopment Plan Volume 2 78 affected by the elimination of a flood-related activity or the weakening of the regulatory requirements for new development. A similar system used in fire insurance rating has had a strong impact on the level of support given fire protection programs. As a result of the rating change, residents of unincorporated Palm Beach County will enjoy a 25% deduction in the flood insurance premiums. It was the first community in the nation to develop a comprehensive flood awareness website. A key purpose of the group is helping each other to enhance their programs and raise their class ratings. The expo features dozens of public and private sector exhibitors and non-profit organizations and interactive activities for attendees. Presently Palm Beach County offers the program on a limited basis to owners of "repetitive flood loss" properties based on the availability of Federal and State funds and the availability of local resources to administer the program. The program provides homeowners with reasonable, cost-effective hazard mitigation options and potential public and private financing alternatives. Post Disaster Redevelopment Plan Volume 2 79 contributes up to 75% of eligible mitigation costs. This post disaster program allows eligible applicants to apply for mitigation assistance funds based on losses suffered by the community. Flood mitigation, particularly drainage improvement projects, has been a major focus of the program. Flood Mitigation Technical Advisory Committee Palm Beach County has established an ad hoc committee of public and private sector flood experts to develop comprehensive flood mitigation strategies and projects without regard to jurisdictional boundaries. The Committee has developed, planned and prioritized over a dozen major projects to date. Among its primary missions, the Strategy serves as a basis for comprehensive mitigation planning, project identification and prioritization, and provides assistance to project sponsors in securing and allocating available federal, state, local and other disaster mitigation assistance funds. Vulnerability While damages caused by storm surge and dike failure can be extensive and costly, historically physical damages from inland structural flooding have been relatively minor and isolated. As a predominantly localized event, inland flooding does not pose a significant threat to the ability of the county, municipalities and businesses to carry on normal operations. People, structures, and infrastructure located within floodplains and areas with poor drainage are most susceptible to inland flooding, particularly to flash flooding. Continued development will certainly contribute to an increased frequency of runoff flooding.