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Home > June 2016 - Volume 38 - Issue 6 > INFOCUS: Discharging Patients AMA Who Leaves and What Happen...
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INFOCUS: Discharging Patients AMA Who Leaves and What Happens to Them?
Roberts, James R. MD
Emergency Medicine News: June 2016 - Volume 38 - Issue 6 - p 14–16
doi: 10.1097/01.EEM.0000484514.71487.95
Dr. Robertsis a professor of emergency medicine and toxicology at the Drexel University College of Medicine in Philadelphia. Read the Procedural Pause, a blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, CEN, athttp://emn.online/ProceduralPauseEMN, and read his past columns athttp://emn.online/InFocusEMN.
What Happens to Patients who Leave Hospital Against Medical...
A Typical Profile
Discharges Against Medical Advice: A Community Hospital Exp...
Profile of AMA Discharges
Read InFocus and Earn CME!
Emergency physicians have a lot to consider when diagnosing and treating complex ED patients. But we have all been in the situation where we spent considerable time, effort, and resources, and a seemingly cooperative patient quite abruptly and certainly unceremoniously decides he (usually he) does not really want to take our advice and opts to leave the hospital. This is a frustrating dilemma, one that is fraught with potential and real complications for the patient and physician.
No universal standard of care exists for ED AMA discharges. Last month I discussed the lack of value of the standard AMA form. Contrary to common physician belief, the hastily signed vague and incomplete AMA form we all have used for decades does little to protect the hospital or physician when a patient has a bad outcome. Good charting generally equates to good medicine, and a poorly written AMA document is literally asking for medical — and legal — problems.
Merely having a noncompliant patient sign a piece of paper, often because you are happy to be rid of him, does not give blanket immunity to caregivers. A fully informed and competent individual has the right to refuse any medical intervention for himself and his children, but everyone loses in an AMA discharge. No law prohibits a patient from being in denial, stubborn, or simply ignorant. Patients must be reasonably informed and deemed competent, however, to leave your ED, and the chart should clearly confirm these caveats.
We don't know much about eventual outcomes, but it turns out that AMA patients often return for an extended and very expensive hospital stay, occasionally in a worsened condition, but not necessarily to the same hospital from which the egress occurred. True disasters are few and far between, but these can be high-profile cases. A death after a recent ED visit is met with great delight by the always-critical 6 o'clock local news. This remains a thorny issue for all EPs.
What Happens to Patients who Leave Hospital Against Medical Advice?
Hwang SW, Li J, et al.
CMAJ 2003;168(4):417
Patients who leave AMA are at risk for bad outcomes and subsequent readmission, often with eventually longer and more expensive hospital stays. The purpose of this study was to examine the rate and predictors of readmission of patients who had left the hospital AMA. The authors, from an urban hospital treating many indigent and homeless patients in Toronto, studied the records of and conducted personal interviews with 97 consecutive patients who left AMA from the general medical service.
The overall AMA discharge rate is one to two percent for inpatients at various hospitals in the United States. The percentage is higher for the lower socioeconomic class, those who lack insurance, and patients from disadvantaged urban areas. Patients from low-income urban hospitals have significantly higher AMA discharges than one would suspect, although the exact number is difficult to obtain. A primary issue of an AMA discharge is a subsequent adverse medical outcome, including a worsened condition on readmission or greater morbidity or mortality. It is well known that HIV-positive patients who leave AMA are readmitted with a related diagnosis on a regular basis. Little information is available on the actual outcome after AMA discharge of general medical inpatients, however.
The definition of an AMA discharge is an elopement or a voiced decision to leave the hospital prematurely. The AMA discharge rate in this study environment — with a high percentage of low-income and homeless individuals — was a high six percent. Control patients were those who were electively discharged. Patients who had a readmission within 90 days were considered to be readmitted.
Patient interviews gleaned that reasons for leaving were varied, including pressing family matters, feeling well enough to go home, dissatisfaction with treatment, feeling bored or fed up, and a general dislike of hospitals. Interestingly, 70 percent had a history of alcohol and drug abuse. Patients did not cite withdrawal or the need to drink or obtain drugs as the proximate cause, but it likely played a role.
The readmission rate for the AMA group at 15 days was impressive: 21 percent vs. three percent for the control group. Readmission rates were higher at 15 days than at 90 days, although both time periods had high readmission rates. Three of the patients who were discharged AMA died during the follow-up period, but none of the deaths was considered directly related to premature departure. Homeless patients left more often than domiciled individuals. Most left within two to five days, but some exited after more than six days of hospitalization. The overall longer length of stay in Canadian hospitals compared with U.S. hospitals may have influenced patients' AMA decisions.
The authors were unable to define specific disease patterns associated with AMA discharge, suggest ways to stop AMA discharge, or proffer ideas to minimize the risk of adverse outcomes. They suggested specific follow-up appointments, providing appropriate prescriptions, and giving a written summary of the hospital stay for other health care providers. A significant number of patients will seek readmission at a different hospital.
Comment: This report characterizes patients leaving AMA from an inpatient medical service, but it is reminiscent of ED patients who similarly discharge themselves. We have precious little time to make a good first impression in the ED or provide personal attention to the warm and fuzzies, such as meals and other expected comfort measures. Our clients are often in a distressed mental state already. No one wins with an AMA discharge, though. It does not seem fair that litigation is even an option if informed consent is appropriate and the patient is otherwise competent. My experience is that charting issues (great doctoring but omnipresent poor documentation) are the plaintiff's best ammunition against the EP. Most of us spend hours with the patient, yet only a few seconds on the paperwork that proves it. You did your best and usually went above and beyond reason, but essentially you were charged with "allowing the patient to sign his life away." Whatever happened to the patient's duties and responsibilities?
Any EP reading this article would feel great empathy. Patients described in this scenario generally fit the profile of those who leave the ED. (Acad Emerg Med 2007;14[10]:870.) They are usually young men, have drug and alcohol issues, and a poor understanding of and little patience with our inefficient health care system. Theirs is a fast-food mentality: They want it their way, and they want it now. Many are frequent denizens of the ED, don't have a family physician or social support, and look to the hospital for the lack of personal attention they crave for their impenetrable medical and social problems.
Coming from a lower socioeconomic and disadvantaged home or homeless environment makes it difficult for physicians to get across extant issues with our lumbering system. Waiting 10 hours for an inpatient bed, or for a tardy then rude consultant, frustrates clinicians also. We rarely ascertain the correct reasons for patients leaving the hospital, but it may be something as simple as going home to feed the cat. Many opt for the AMA route by denying their condition, having to take care of a child or ailing family member, being afraid of a large hospital bill, or needing another drink or a dose of heroin. Interminable waits and delays for non-life-threatening problems define many ED elopements.
Weinhart, et al., reported an amazing 54 percent readmission rate for patients discharged AMA from an urban teaching hospital, concluding that Medicaid status was an important predictor of premature discharge. (J Gen Intern Med 1998;13[8]:568.) Fixed income senior citizens often feel an honest responsibility to pay their bill. One can certainly see how they would be concerned about the ubiquitous $20,000-a-day admission. Never make admission decisions based on finances, but it also doesn't make sense in borderline cases to spend someone's three-month Social Security income because you are afraid to discharge a patient with an unknown diagnosis or merely because of defensive medicine. If true financial issues sway a borderline admission and it's essentially a joint decision to go home, my advice is to construct a formal, albeit amicable, AMA discharge paragraph. Make it is crystal clear that your recommendation was admission or further testing. You want the patient to remember that it was his decision to leave; you did not obstruct admission because he did not have insurance.
This study could not predict which patients would be readmitted or offer ways to decrease incidence. I am not surprised that many went to another hospital. We all get frustrated when patients come to our ED having just spent a week at another hospital, particularly without records. Seeing a patient who just left another ED is likewise outrageous. If you discharge someone AMA and you have paid attention to the intricacies of the properly executed AMA form, give the patient a copy of pertinent laboratory tests, CT scans, and ultrasounds to make life easier on your colleagues. Also include a copy of the AMA form he just signed. You might save yourself an annoying phone call from a similarly overworked and frustrated colleague on the rare chance that the patient keeps these documents. The patient's version of the story to the next physician, detailing exactly why he left your hospital, is rarely the same as yours, so be prepared for an irate call from some similarly stressed out emergency physician when he hears his complex and unhappy patient was just in your hospital.
AMA discharge of an indigent patient does not help the hospital's financial bottom line. Readmission of an AMA discharged patient is extremely expensive. (Int J Clin Pract 2002;56[5]:325.) The average LOS for the primary admission was 2.3 days in one study, compared with the LOS on readmission of 4.7 days. The cumulative cost of a discharge-readmission was calculated to be 56 percent higher than expected for the specific problem.
Discharges Against Medical Advice: A Community Hospital Experience
Seaborn Moyse H, Osmun WE
Can J Rural Med
2004;9(3):148
These authors note that a Canadian community hospital experience with AMA discharges is probably less dismal than those of an inner city indigent hospital. Their AMA discharge rate was only 0.6 percent. Patients leaving this hospital, however, were also more likely to be male and have a greater frequency of substance abuse and psychiatric conditions. Canadian physicians' charting habits were dismal, worse than their American colleagues. Only 80 percent of the charts had AMA documentation, and only 23 percent included evaluation of patient competency. These authors also frustratingly conclude that potential interventions to deter AMA discharge are limited. They suggest that early identification of patients at risk may facilitate the outcome, decrease AMA discharges, and improve eventual health outcomes. Exactly how this can be determined or implemented is quite elusive.
Comment: Exactly why patients sign out AMA is somewhat inscrutable. It's probably not just because they are angry or totally dissatisfied with the ED interaction. Dubow, et al., contacted 52 ED AMA discharged patients and found a surprisingly high satisfaction score for the hospital and treating physician (70%). (J Emerg Med 1992;10[4]:513.) Eighty-two percent of patients, however, did not "agree" with their physician's treatment plan. Curiously, the majority of patients said they would leave AMA again under similar circumstances. I can never understand what is more important or pressing at home than their health. Go figure.
Green, et al., suggest the majority of patients leave for personal reasons, such as sickness or disability of a family member, a plethora of financial problems, and legal issues, such as a court date. (Am J Drug Alcohol Abuse 2004;30[2]:489.) I suggest that the real reason patients leave AMA is rarely clear-cut or forthcoming. We never get the true answer, and most nurses and physicians simply don't care; it's human nature. Physicians, in fact, tend to be indignant and angry that an ungrateful patient precipitously decides to up and leave. It's difficult to ameliorate that mindset after you spent countless hours and tax dollars trying to unravel the vagaries and complaints of a drug abuser, alcoholic, or psychiatric patient.
Berger emphasizes that noncompliance to more urgent ED medical advice parallels noncompliance to multiple, less urgent outpatient medical interventions. (J Hosp Med 2008;3[5]:403.) Noncompliance is posited to be related to treatment side effects, costs, inconvenience, child care or pressing family member needs, psychosocial burden, and patient-physician relationships. If office advice for chronic conditions is heeded 20 percent of the time, that's considered "good."
The data specifically about ED AMA discharges are sparse. Fernandes, et al., concluded that ED AMA patients have a low acuity and often leave because of waiting times, but I have not seen any good data about the outcome of ED patients who leave or strategies to decrease incidence. (Ann Emerg Med 1994;24[6]:1092.) Lee, et al., reported the seriousness of cardiac disease in ED AMA discharges for chest pain had a varying prognosis, and it was not always benign. (J Gen Intern Med 1988;3[1]:21.) Leaving AMA after three or four days in the medical service is probably safer than leaving after a few hours in the ED. Contrary to my intuition, it has not been proven that adverse outcomes and revisits to other hospitals is higher in ED patients than for patients leaving the general medical ward.
Patients with HIV have a high incidence of AMA discharge. Anis, et al., noted a 13 percent AMA discharge rate of HIV patients in Vancouver. (CMAJ 2002;167[6]:633.) Chan, et al., reported that AIDS patients who are IV drug abusers have an AMA discharge rate of up to 25 percent. (J Acquir Immune Defic Syndr 2004;35[1]:56.) Offering inpatient methadone therapy reduced that rate in this high-risk group.
A truly disastrous medical outcome from an AMA discharge is likely uncommon; nonetheless, you don't want to be on the wrong end of a high-profile problem. No one has come up with an insightful plan to prevent the AMA discharge of a bona fide sick or potentially problematic patient. You can intuit that a patient won't stay for very long in some cases and skillfully try to derail the AMA before it happens, using all of our common tactics. That's a pretty hefty mandate in the ED but worth a try. Getting the family involved, apologizing for inconvenience, treating withdrawal, expediting tests and admission, and minimizing financial concerns are partial strategies, but in many cases, you just can't win.
Multiple authors have noted the high AMA discharge rate for psychiatric patients is as high as 50 percent. The next time you are at your wit's end with a bipolar patient in the ED, consider the plight of your psychiatric colleague. This topic is so important that I will devote an entire column next month to the psychiatric patient who wants to leave AMA.
The overall AMA discharge rate from a medical service and ED is one to three percent but up to six to seven percent in those fitting a high-risk profile.
Psychiatric services may experience AMA discharges up to 35 to 50 percent.
A lower socioeconomic status/disadvantaged urban population has a higher AMA discharge rate.
Other AMA variables include feeling better, lack of a primary care physician, lack of insurance, patient-physician friction, a child or impaired relative at home, denial, and feeling bored and frustrated.
Patients with HIV disease, drug or alcohol abuse, homelessness, and young men have higher AMA discharge rates.
The readmission rates for AMA discharged patients may be as high as 20 percent within 90 days.
The cost of readmission of an AMA discharge is significantly higher than an extended first stay.
The best way to thwart an AMA discharge is unknown.
The outcome of ED AMA discharges has not been clarified, but ED patients may have a lower acuity and leave because of long waiting times.
No specific medical diagnoses, conditions, or initial complaints have been identified as high risk for ED AMA discharge.
Earn CME by completing a quiz about this article. You may read the article here, on our website, or in our iPad app, and then complete the quiz, answering at least 70 percent of the questions correctly to earn CME credit. The cost of the CME exam is $10. The payment covers processing and certificate fees.
Visit http://CME.LWW.com for more information about this educational offering and to complete the CME activity. This enduring material is available to physicians in all specialties, nurses, and other allied health professionals. Lippincott Continuing Medical Education Institute, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Lippincott Continuing Medical Education Institute, Inc., designates this enduring material for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity. This activity expires June 30, 2017.
Learning Objectives for This Month's CME Activity: After participating in this CME activity, readers should be better able to identify which patients might leave against medical advice and employ tactics to deter their exit.
Reader Feedback: Readers are invited to ask specific questions and offer personal experiences, comments, or observations on InFocus topics. Literature references are appreciated. Pertinent responses will be published in a future issue. Please send comments to emn@lww.com.
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What Happens to Patients who Leave Hospital Again...
Discharges Against Medical Advice: A Community Ho...
Emergency Medicine News38(6):14-16, June 2016.
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My grandfather was a navigator in the Mighty 8th United States Army Air Forces, flying with his crew on a B-24 Liberator. His unit, the 700th Bomb Squadron, part of the 445th Bomb Group, was enlisted for the Rhineland Campaign.
Per Wikipedia, ..."half of the U.S. Army Air Force's casualties in World War II were suffered by Eighth Air Force (more than 47,000 casualties, with more than 26,000 dead)."
I know that my grandfather met with his former crew mates as long as they were living. They all stayed in touch. I imagine that once you share what they did, the ties to one another would be very strong. I only wish that I had the name of his fellow crew. Maybe someone will see this photo and know some of the other men.
I wanted to share this family photo of my grandfather Joe Damiano with the community. Location: RAF Tibenham, England. Date: 1943.
Click here for the image details page or here for the full-sized version (564 x 399).
Don't keep us guessing, Cheryl! Which one is your grandfather?
How kind of you to ask! Standing back row, second from the right. Thanks for asking!
I think we should be able to identify the crew. I have identified everyone in two B17 crews. I'll get back to you unless someone beats me to it.
Oh my gosh!!! If we can identify even a couple I will be jumping for joy!
Shared Photo: Joe Boone and brothers: L-R Sam, Joe, Charles and Will. Unknown Friend on far right.


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Sonesta Fort Lauderdale Beach adds new catering, meetings managers
by Elliott Mest |
The Sonesta Fort Lauderdale Beach. Photo credit: Sonesta International Hotels Corporation
Sonesta Fort Lauderdale (Fla.) Beach, located on the corner of A1A and Sunrise Boulevard, appointed Cindi George as catering manager and Lindsay Pletch as executive meetings manager. Effective immediately, George will be responsible for executing day meetings and all social gatherings with the exclusion of weddings. Pletch will handle the needs of small groups up to 30 rooms.
Cindi George: Photo credit: Sonesta
International Hotels Corporation
"We are very pleased to have such passionate, dedicated professionals join the Sonesta Fort Lauderdale Beach family," Eduardo Fernandez, GM of the hotel, said in a statement. "Cindi and Lindsay both have track records of success within their individual specialties. Their experience, combined with their enthusiasm, makes them the perfect assets to our team during a very exciting time for the property and the destination."
George has more than 25 years of account management experience, including 10 years of event and catering sales experience. She will be responsible for the sales and execution of corporate events. Most recently, she was the sales and marketing manager for Grateful Palate Catering and Events. Before that, she served as the account sales manager for Windridge Yacht Charters and the event sales manager for Lucky Strikes Lanes' Miami Beach location, where she became a national top achiever.
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Lindsay Pletch. Photo credit:
Sonesta International Hotels
Pletch, who most recently served as the sales manager of the Desmond Hotel in Albany, N.Y., will be responsible for all aspects of the sales process and the execution of corporate groups up to 30 rooms. In her previous position at the Desmond, a family-owned and -operated hotel, she served in sales, event and banquet managing positions. While getting her bachelor's degree in hospitality management from Cornell University, Pletch worked at The Statler Hotel, where she was promoted to sales manager in just four years.
Sonesta Fort Lauderdale Beach has 240 guestrooms including 23 suites, and offers panoramic views of the 7-mile stretch of Fort Lauderdale Beach or the Intracoastal Waterway. Sonesta Fort Lauderdale Beach caters to both business and leisure travelers, and is centrally located on the corner of Sunrise Boulevard and A1A, 8 miles from Fort Lauderdale/Hollywood International Airport and minutes from the Las Olas Arts & Entertainment District and Port Everglades.
Operations Human Resources People on the Move Appointments Sonesta Resorts and Hotels
Elliott Mest
https://twitter.com/celmest
https://www.linkedin.com/in/elliott-mest-a16a746a

redpajama_set_name: RedPajamaCommonCrawl


Dhruv V.K., Sahu A., Bansal A.K., Shashikala Dhruv (Thakur), Shrivastav P.K., Baghel B., Viswanadham K. K., Sharma S.
Objectives: To know the effects of Pipecuronium Bromide used as general anaesthesia during caesarian section on neonates, if any? Material and Methods: Eighty five mothers who have undergone Caesarian Section were included in the study (sixty five in study and twenty in control group). Statistical analysis: Chi-square tests, Proportion etc. were used for statistical analysis. Results: 85% had an average apgar score of 9.19 and 9.92 at 1 minute and 5 minutes interval. Only 15% had an average Apgar score of 5.77 to 8.0. Preoperative foetal distress and prematurity were the two factors leading to a poor scoring. Conclusion: It was concluded that pipecuronium Bromide can be used safely during Caesarian Section without any adverse effects on Neonates.
Dhruv V.K., Sahu A., Bansal A.K., Shashikala Dhruv (Thakur), Shrivastav P.K., Baghel B., Viswanadham K. K., Sharma S.. An Assessment of Neonatal Status Using Apgar score: Pipecuronium Bromide Used as an Anaesthesia Drug during Caesarian-Section. Research J. Science and Tech. 2011; 3(4): 189-191.


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Top 5 Favourite Game Series of all Time
I haven't made many posts on video games on this blog yet, but they have been a huge part of my life since I can remember. Today, let's talk about five of my favourite video game series of all time and which game of each franchise is my favourite. A lot of these bring back many nostalgic memories for me; so join me and let's count down my top 5 favourite game series of all time, in no particular order.
Before I start, here are some honourable mentions:
Grand Theft Auto – FAV of the series- Vice City
Fallout – FAV of the series – Fallout 3
Elder Scrolls – FAV of the series – OBLIVION
Tekken – FAV of the series – Tekken 3
Batman Arkham Series – Batman Arkham City
FAV OF THE SERIES: MORTAL KOMBAT 2011
Mortal Kombat 2 was the first game I ever played on the Sega Megadrive (Genesis in America) and I fell in love with the game automatically. From the movie to the games, my obsession with the series knew no bounds, I learnt the entire history and mythology of Mortal Kombat and have been obsessed with it for years. My favourite character is Baraka, the design of him just made little three year old me love him and he would always be the character I played in MK 2. As the series went on there have been a lot of highs and a few lows, my favourites being; Mortal Kombat 2, Mortal Kombat Deception, Mortal Kombat Shaolin Monks and my absolute favourite Mortal Kombat 2011.
A lot of critics disregard the game's story to just cheesy fun, but I believe that there is so much detail in the story of Mortal Kombat and such strong mythology, it's outstanding. The reason Mortal Kombat 2011 is my favourite is that the story mode was revolutionary for a fighting game, the challenge tower was amazing and they finally brought the series back to its 2D routes which brought interest back in the fighting game genre again, not just Mortal Kombat. They normally release one every four years, so I'm hoping in E3 they will announce another one coming next year and if they do, you can be sure I will be making many posts about that. I also still stand that the movie is still the best video game movie ever made!
FAV OF THE SERIES: GOD OF WAR 1
God of War, is the most epic game series ever created. From the moment God of War opens showing Kratos jump from the highest peak in the whole of Greece, we knew we were in for something special. When playing the first three games, it truly felt like you were playing a Greek myth. The music is always cinematic quality, the graphics and art style are always fantastic and God of War 3 has one of the biggest bosses in all of gaming.
The reason that God of War 1 is my favourite of the series is that I love the backstory of Kratos. Seeing him plead to Ares and how he got the chains around his wrist, and the reason his skin is covered in white. Although the first is my favourite the second and third games are still brilliant, which I love more than nearly any other game. The new God of War is one of my favourite games to come out in years. Even the games which are not as good, such as the PSP games and Ascension are still great games, just not as good as the original three or the new one.
FAV OF THE SERIES: DEVIL MAY CRY 1
Similar to Mortal Kombat, I was obsessed with Devil May Cry as a child and I would delve deep into the backstories to every character, to fully understand the mythology of the series. God of War may have had the epicness, but Devil May Cry had the coolness and the technical gameplay. Every move that Dante does makes you feel like a badass, the move-set is also so deep that it was more like a fighting game, where practising can make you create eye dropping combos.
My favourite of the series is the first one, the reason for this is because of how it started; the game started as a Resident Evil game, therefore the game had a darker tone than the rest of the series; the inside of the castle was incredibly scary, the marionettes, in particular, used to petrify me. Devil May Cry 2 dropped in quality significantly, but then Devil May Cry 3 and 4 brought the series back and made it an iconic series for the PS2 and early PS3 era. In 2013, DMC, a reboot for the series came out with Dante with black hair, although fans hated this game because of what they had done to Dante, I still loved the game, not as much as 1,3 or 4, but I think it was still a great action game.
FAV OF THE SERIES: DARK SOULS 1
I remember in 2013, YouTubers were shouting about a little game called Dark Souls. They were showing how it was one of the hardest games ever made and the art style looked exactly like the kind of thing I would love. I went straight to one of my local retail shops and bought the collector's edition for the game. I was amazed. It had been years since a game had gripped me like this, it had been out for two years by this point, but I felt that this was still a game that not a lot of people knew about and was the perfect game made for me. The game also made me find out about the manga Berserk, which became one of my favourite stories ever, so I have a lot to thank Dark Souls for.
As soon as I completed Dark Souls I went back and got the collector's edition of Demon's Souls, it was good, but not as good as Dark Souls. Then obviously the series blew up not long after and continued to have two great sequels and an off-shoot game called Bloodborne which is my second favourite in the series. There have been countless rip-offs of the series since it's rise in popularity, but none have come close to the original Dark Souls or Bloodborne in my opinion and I hope whatever the developer has planned next will be something revolutionary like this amazing series.
FAV OF THE SERIES: RESIDENT EVIL 4
Compared to the other series on this list, Resident evil is a mammoth of a series. It has seven titles in its main series, but dozens of spin-off games, on nearly all systems since it's original launch on the PlayStation one. The game has evolved throughout the years and because of the number of games in the series, there have been many highs, but a whole load of lows. In my opinion, the main series are all great games except for number RE6, which was a huge letdown, it didn't know what it wanted to be. Apart from that, all are great, RE5 feels like a departure from the horrific style of the first four, but was still a great game, RE7 which came out last year, is probably the scariest in the series.
My favourite of the series is Resident Evil 4, probably because it was the first one of the series that I played and it crafted what a third person shooter should be. It had the perfect mixture of horror and action, which no other game in the series got right. Although RE4 is my favourite, the Resident Evil 1 remake is also very high on my list, as well as Resident Evil 7. As for the spin-offs, there are a lot more lows, but Resident Evil 0 and Code Veronica are fun games in the series (probably because Code Veronica was supposed to be RE3).
So those were my favourite game series of all time, each of those has at least two of my favourite games. I will probably make a list one day of my favourite games ever.
Thank you for reading, I hope this blog makes you want to play some of these games, if you haven't already, or just brings memories back, or when you played them.
Please like, comment and follow my blog for more posts like this and anything that I love talking about.
Also, let me know what your favourite game series is! Thank you!
LIST, video games
batman, best video game series, bloodborne, dark souls, devil may cry, edler scrolls, fallout, god of war, grand theft auto, gta, mortal kombat, resident evil, tekken
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Francis Ferdinand
Francis Ferdinand (1863-1914) was archduke of Austria and heir apparent to the Austro-Hungarian throne. His assassination in 1914 was the immediate cause of World War I.
Born on Dec. 18, 1863, Francis Ferdinand (German, Franz Ferdinand) was the oldest son of Archduke Karl Ludwig, brother of Emperor Francis Joseph. He started a military career at the age of 15, serving in Hungary, Upper Austria, and Bohemia. The suicide of the crown prince Rudolf (1889) and his own father's death (1896) made him heir apparent.
Partly to cure a lung ailment and partly to enlarge his knowledge, Francis Ferdinand took several cruises during the 1890s, one of which brought him around the globe. Following his return he spent some time in Bohemia (1894-1895), but his illness soon forced him to spend several years on the Adriatic and the Mediterranean coasts. In the meantime he advanced in rank (becoming general of the cavalry in 1899), but this did not lessen his long-standing contempt for Viennese high society or his differences with the Emperor. He crowned his contempt by his morganatic marriage (July 1, 1900) to Countess Sophie Chotek.
Francis Ferdinand regarded the nationality question as the most serious problem of the empire. Initially he sought a solution in terms of "crownland federalism," with the historic borders more or less retained (except for Hungary). Later he favored the idea of the "United States of Greater Austria," which called for a thorough restructuring along ethnic lines. Simultaneously, Francis Ferdinand also toyed with the "trialistic" solution, which was to be achieved by granting the South Slavs an equal partnership with the Austrians and Hungarians in the empire. Finally, due largely to threatening Serbian irredentism, he returned to a modified dualism, calling for a special position for Bosnia-Herzegovina as the "Kingdom of Rama."
In foreign affairs Francis Ferdinand favored the pro-German orientation but also wished to restore understanding with Russia. This desire prevented him from advocating a policy of final solution against the growingly bellicose Serbia.
Francis Ferdinand's influence grew, and by 1913 he was inspector general of the combined armed forces. In this capacity on June 28, 1914, he visited Sarajevo and was assassinated by a group of Serbian conspirators. The fateful bullet, which unleashed the war, was fired by Gavrilo Princip.
Further Reading on Francis Ferdinand
The standard biography of Francis Ferdinand by Rudolf Kiszling, is available only in German. Fortunately there are also a number of good English-language works, most of which, however, place too much emphasis on the assassination and the "war guilt" questions. The best and most recent of these are Joachim Remak, Sarajevo: The Story of a Political Murder (1959); Hertha Pauli, The Secret of Sarajevo: The Story of Franz Ferdinand and Sophie (1965); and Vladimir Dedijer, The Road to Sarajevo (1966).


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1. Built-in speakers. You can take off your earbuds and switch these speakers on. Handy for times when you want tunes, but cannot wear earbuds (like talking with your buds).
2. A built-in jack. This way you can plug your MP3 player directly into an AUX port, without having to switch to another cord entirely. This would flip out of one of the earbuds like a switchblade.
3. Visualizer. Okay this one is entirely cosmetic, but I always liked the idea of a visualizer on the earbuds or the MP3 player itself. Sure it's a bit Lady Gaga, but it looks cool.
4. A spare jack port for sharing the audio feed. Sure it seldom ever happens, but this would be nice feature that would allow a friend to listen in. Handy for when you want to a share a film on a long flight. You could buy one of those splitters, but they are never around when you need one.
1. I think most people just crank the volume with the buds hanging over their neck to accomplish the same thing; the sound quality couldn't be better, could it?
3. a visualizer could be a good reminder of how loud your music is – and to turn it down if it's in the red, so you don't damage your hearing.
1. Cranking up headphones to use as speakers makes for poor sound, only hearing the upper and lower range of the music in a squeaky pitch. Some dedicated external speakers on the headphones would allow for some audible and clear music, though at this size it wouldn't be amazing quality either, but would do the job.
2. There are headphones out there where you can unplug each of the earbuds from the cord using smaller versions of the standard jack – this was done for sound quality. However I opted for this design so you don't have to worry about losing any earbud pieces.


Super handy 25g take everywhere size. 25g provides many applications, especially if you are using it mostly for "face, Neck, Hands". All-around, everyday - High protection Insuncare SPF30 sunscreen is great for all active people, young and old, pursuing fun in the sun. The water-free formulation does not dissolve in water while swimming or when sweating and it doesn't sting eyes or broken/sensitive skin. So great for tourists out and about, and great under makeup. Great for the kids at school, at the pool or the beach, or just out for the day playing in the sun. The moisturising base contains Aloe, VitE and VitB - caring for your skin long after sun. Hypoallergenic and kind for all skin types. Broad spectrum UVA & UVB protection.
People with sensitive skin that may otherwise react to sunscreens and other skin cosmetics can normally use Insuncare with confidence. Because it contains no water, no microbes can exist, so it is sterile by the manufacturer. There are no preservatives (parabens) or surfactants in the unique formulation, so way less chance of irritation on your skin.
For face we recommend spreading product between palms and the rub into face and neck, and hands ensuring a good cover (see video home page). Do this before sun, in the morning is ideal before you leave for (or on journey to) your activity. Does not sting eyes or broken or sensitive skin due largely to no preservatives being used.


Celeste Legaspi (born 18 March 1950) is a Filipino singer and actress. Her singles and albums reached gold or platinum status during the 1960s, 1970s and 1980s. She is the daughter of National Artist for Visual Arts Cesar Legaspi. She spearheaded the Organisasyon ng Pilipinong Mang-aawit (OPM), a group which aimed to promote and propagate Original Pilipino music. She is married to Nonoy Gallardo, one of the premier OPM composers.
Celeste Legaspi (nicknamed Maricelle) is third of the five children of National Artist Cesar Legaspi and his wife who once classified as coloratura. Celeste started singing during her kindergarten years. By 1955, she started singing professionally with The Ambivalent Crowd, earning ₱25 per performance.
While in college, she appeared in Show Boat as Magnolia followed by her performance as Nancy in the Philippine presentation of Oliver!. But she later confessed that her performance in Show Boat scared her. "There I was, cracking every night, unable to be heard from the musical accompaniment, with Mama holding on to my sister Diana's hand. As a result I was disillusioned with my singing and with my course then--nursing," Legaspi told in an interview.
But the then 16-year-old Celeste Legaspi didn't give up her singing. Her singing career flourished upon shifting her course to Communication Arts at Maryknoll College (now Miriam College). She joined The Ambivalent Crowd, became a college graduate in 1971, and eventually married to Dominador 'Nonoy' Gallardo in March, 1972, who was then an advertising man.
In 1972, she left The Ambivalent Crowd and joined the Up from Down Under Band as a soloist for a three-month stint at Wells Fargo. Then she became part of the Time Machine which at the time had a songstress named Didith Reyes and Anthony Castelo who would both conquer the OPM charts in the years ahead.
Legaspi's career rose further upon joining the ASEAN Tour in 1975 followed by a solo concert at the Cultural Center of the Philippines' (CCP) Little Theater where Rolando Tinio, one of the Philippines' literary geniuses, featured her in Filipino translations of popular songs at that time, most of the songs appeared in her Celeste ... Popular Songs Vol. 1 album. The album featured Celeste's heartwarming Filipino renditions of Mini Ripperton's Loving You, Diana Ross' Theme from Mahogany, and The Lady Is A Tramp.
The impressive feat was followed by successful dinner-theater presentations in 1977 of Manila, Manila which won her an Aliw Award for Best Dinner Theater performance for that year. She also starred in Doon Po Sa Amin and Jesus Christ Superstar in 1978, each garnering Best Dinner Theater awards.
Celeste Legaspi claims she is greatly influenced by Barbra Streisand, Liza Minnelli, Lena Horne, and Ella Fitzgerald. During one of her interviews she said that her type of music rests on elements of blues and those which intend to break the monotony of pop music.
Her theater career began when she starred in two college productions. She sang the part of the first woman in the play "Tales of the Manuvu" (1977), where she shared the stage with Hajji Alejandro. Her other stage works include an appearance in the hit musical Katy! (1988) for the Cultural Center of the Philippines' Tanghalang Pilipino, and the portrayals of Babae in North Diversion Road (1988), Caridad in the zarzuela Paglipas ng Dilim (1991), and Candida in Larawan (1992).
Along with theater icon Zeneida Amador, she was awarded as the first recipient of "Natatanging Gawad Buhay!" Award given by the Philippine Legitimate Stage Artists Group, Inc. (Philstage). The award embodies her lifetime contribution and marvelous efforts for the production of original Filipino musicals which flourished for over two decades since the 1980s. Legaspi, being the founding president of the Organisasyon ng Pilipinong Mang-aawit and Philstage, was key in establishing the Philippines' sole alliance of professional performing arts companies and organizations.
Legaspi appeared in films such as Lino Brocka's Santiago (1970), Stardoom (1971) and Sa Kabila ng Lahat (1991), Mamang Sorbetero (1979), Tatlong Ina, Isang Anak (1987), Anak ng Pasig (1993) and Ishmael Bernal's Wating (1994). She also sang the main theme song on Kahit ang Mundo'y Magunaw (1975), a Manuel Cinco film starring Pilar Pilapil and Christopher De Leon. She is part of the cast of the 2017 film Ang Larawan.
Legaspi is also a TV actress. One of her earliest TV exposures is when she was eight years old appearing in a Vicks commercial. In 1975-1976 she received the Sinag Awards from the Pambansang Akademya ng Telebisyon sa Agham at Sining (PATAS) for her performance in the TV special At Long Last Celeste, and for the TV weekly musical Iba't-ibang Celeste. She also guested in a drama series, Cebu in 1991. In 2014, she portrayed Maricel Soriano's protective and aristocratic mom in GMA-7's in the successful teleserye, Ang Dalawang Mrs. Real.
Legaspi is a successful recording artist, having produced albums and singles that reached gold and platinum status during the '70s and '80s. Her album Ako si Celeste under Blackgold Records was awarded gold, and produced hit singles "Saranggola ni Pepe", "Tuliro", and "Gaano Ko Ikaw Kamahal?". The Celeste album included "Mamang Sorbetero". Her albums Bagong Plaka, Lumang Kanta Vol. 1 and 2 albums under Wea Records both reached the double platinum mark.
She won several awards including Outstanding Performance award from the Song Festival in Tokyo, Japan, where she sang "Puso Mong Nagmamahal" (1976), Tinig Awards for live entertainment (1977, 1979, and 1990), and the Aliw Award for Entertainer of the Year (1978).
ALIW AWARDS: Best Dinner Theater Performance: Manila, Manila (1977); Doon Po sa Amin (1978); Jesus Christ Superstar (1978). Entertainer of the Year (1978).
^ Ang, Walter. "Hey, Madame Producers!". WordsOfWalter.blogspot.com.


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Q: Clean emails async using Task.Factory What I'd like to do is have my code take a list of emails and feed each one to a service to be verified as valid asynchronously.
The service I'm using is Cobisi .NET Email Verify that allows you to verify an email as valid to various verification levels by calling their Task-based asynchronous API.
Using this blog post (http://www.hanselman.com/blog/BackToParallelBasicsDontBlockYourThreadsMakeAsyncIOWorkForYou.aspx) I think my code will asynchronously validate my list of emails and return an array of Task< bool > representing the emails that passed validation, however I'm not sure how to use this array in Task.Factory.ContinueWhenAll() to return a collection of clean emails.
Here is my code so far
Async Email Validation Method:
public async Task<bool> ValidateEmailCleanAsync(string email)
    {
        using (var _engine = new VerificationEngine())
        {
            var verification = new Verification(email);
            await _engine.RunAsync(verification, VerificationLevel.CatchAll);
            return verification.State.Result.LastStatus == VerificationStatus.Success;  //returns true if validation is passed or false if not
        }
    }

Task Factory To Validate Emails:
Task.Factory.ContinueWhenAll(
            (from email in cleanEmailList1 select ValidateEmailCleanAsync(email)).ToArray(),
            completedTasks => { /* Create New String Collection For Clean Emails */ });

Is there a way to put in some code where my comment block is to either build a new collection of clean emails or add them to a pre-constructed collection?  Is there a better way to accomplish what I'm trying to do?

A: Rewrite the fork-join to use await and everything becomes simple again:
var tasks =
  (from email in cleanEmailList1 select ValidateEmailCleanAsync(email)).ToArray();

await Task.WhenAll(tasks);

ProcessTasks(tasks);

ProcessTasks can be anything you like.

redpajama_set_name: RedPajamaStackExchange


On friday, Apple CEO Steve Jobs announced the iPhone case giveaway to consumers to fix the "death grip" problem: the wireless signal is sometimes muffled because the user is holding the device with a bare hand. This dilemma has been voiced by many users ever since the phone's release in the US three weeks ago. Despite the company's denial of such a problem, their free issue of cases will apply to the more than three million people who have already purchased the phone, as well as new buyers through September 30. People who have previously bought a $29 Bumper case will be refunded.
They are also offering a full refund for the phone within thirty days of purchase (with no restocking fee) for unsatisfied users.