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text: Patient Preferences for Anesthesia Outcomes Associated with Cesarean DeliveryCarvalho, Brendan, MBBCh, FRCA*; Cohen, Sheila E., MB, ChB, FRCA*; Lipman, Steven S., MD*; Fuller, Andrea, MD*; Mathusamy, Anbu D., MD†; Macario, Alex, MD*Section Editor(s): Birnbach, David J. Anesthesia & Analgesia: October 2005 - Volume 101 - Issue 4 - p 1182-1187 doi: 10.1213/01.ane.0000167774.36833.99 Obstetric Anesthesia: Research Report Free Abstract In Brief Author InformationAuthors Article OutlineOutline Article MetricsMetrics When deciding on neuraxial medication (e.g., spinal opioids) for cesarean delivery (CS) under regional anesthesia, anesthesiologists make treatment decisions that "trade off" relieving pain with the potential for increased risk of side effects. No previous studies have examined obstetric patients' anesthesia preferences. Researchers administered 100 written surveys to pregnant women attending our institutions' expectant parent class. We determined patients' preferences for importance of specific intraoperative and postoperative anesthesia outcomes using priority ranking and relative value scales. We also explored patients' fears, concerns, and tolerance regarding CS and analgesics. Eighty-two of 100 surveys were returned and analyzed. Pain during and after CS was the greatest concern followed by vomiting, nausea, cramping, pruritus, and shivering. Ranking and relative value scores were closely correlated (R2 = 0.7). Patients would tolerate a visual analog pain score (0–100 mm) of 56 ± 22 before exposing their baby to the potential effects of analgesics they receive. In contrast to previous general surgical population surveys that found nausea and vomiting as primary concerns, we found pain during and after CS as parturients' most important concern. Common side effects such as pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, e.g., inclusion of spinal opioids given in adequate doses. IMPLICATIONS: Medical care can be improved by incorporating patients' preferences into medical decision making. We surveyed obstetric patients to determine their preferences regarding potential cesarean delivery anesthesia outcomes. Unlike general surgical patients who rate nausea and vomiting highest, parturients considered pain during and after cesarean delivery the most important concern. *Department of Anesthesia, Stanford University School of Medicine, Stanford, California; and †Bronx-Lebanon Hospital, Bronx, New York This study was conducted at Lucile Packard Children's Hospital and Stanford University School of Medicine, Stanford, CA. Accepted for publication March 29, 2005. This study was funded internally by the Department of Anesthesia, Stanford University School of Medicine. The authors involved in this study received no external support. Address correspondence and reprint requests to Brendan Carvalho, MBBCh, FRCA, Department of Anesthesia, H3580, Stanford University School of Medicine, Stanford, CA 94305. Address e-mail to firstname.lastname@example.com. Abstract Methods Results Discussion Appendix 1 Appendix 2 References Cited By When providing regional anesthesia for cesarean delivery (CS), anesthesiologists make decisions about the use of certain neuraxial medication (e.g., spinal opioids, clonidine) which, although improving analgesia, may increase the risk of side effects. Most anesthesiologists prioritize pain relief as their primary concern and accept increased side effect profiles (1). In the traditional physician-oriented model of medical practice, patient preferences often are not discussed (2). However, most patients are anxious preoperatively and may fear anesthesia more than surgical complications (3). Moreover, anesthesiologists and surgeons poorly predict patients' preoperative anxiety and fear (3). We are unaware of any previous studies that examined obstetric patients' anesthesia preferences before undergoing CS. Several studies of the preferences of general surgical patients undergoing general anesthesia indicate that patients may be prepared to tolerate pain in order to avoid nausea and vomiting (4–6), whereas others indicate pain is the primary concern for patients undergoing surgery (7–9). Obstetric patients are different from the general surgical population because of additional concerns about the baby's exposure to anesthesia and different peripartum surgical recovery needs, including breast-feeding and caring for a newborn baby. Nausea and vomiting are very common pregnancy-related side effects and may also affect pregnant patients' preferences for potential anesthesia outcomes compared with the general population. Furthermore, women tend to be more anxious about their anesthesia compared with men (7,9). Awareness of patients' needs and desires for pain relief and potential side effects is important when planning anesthetic care. Patient satisfaction and potentially the quality of medical care may be improved by addressing patients' preferences for pain relief and anesthesia (2). The goal of this study was to determine patient preferences for anesthesia outcomes associated with CS. Back to Top | Article Outline Methods After obtaining IRB approval and informed consent, we distributed 100 written questionnaires from August 2002 until January 2003. We approached pregnant women (n = 100) attending a prenatal class designed to educate patients about CS at Stanford University Hospital at random to participate in this study. No formal CS anesthesia education was given before the subjects took the survey. The preoperative visit and prenatal class are routine at our institution and are attended by any expectant mothers and not necessarily those scheduled for a CS. The study investigator explained the study and distributed a patient information sheet describing study aims and patient rights. Stanford University Hospital, California, performs 5300 deliveries per year and has a regional anesthesia rate for scheduled CS of >97%. The survey collected standard demographic data including age, race, income, education, and marital status as well as information regarding previous experience with surgery and/or CS and related side effects of anesthesia. A list of potential clinical anesthesia outcomes was derived from a complete list obtained from a computerized MEDLINE search using the term "anesthesia outcome, complication." The final list used was narrowed to 9 important items for purposes of the study plus a side effect-free recovery for a total of 10 outcomes (Appendix 1). These anesthesia outcomes were similar to a previous study by our research team on the general surgical population (5). The research team created simple descriptions to reflect a number of symptoms focused around a particular outcome; five senior board-certified anesthesiologists in our department reviewed and edited these descriptions for validity and accuracy. To determine women's preferences for specific intraoperative and postoperative anesthesia outcomes and potential side effects, survey respondents were asked to rank the importance of these outcomes. Both priority ranking and relative value scales were used to overcome the difficulty of establishing patients' subjective judgments of side effects that characterize anesthesia. To understand these ranking techniques, we gave patients detailed written instructions. For example, "rank each of these outcomes (you could experience any of these) in relation to each other from 1 to 10 from the most desirable (1) to the least desirable (10). Next, pretend that you are given $100 in order to prevent the following undesirable outcomes of anesthesia. Distribute the $100 such that the more money you spend on a condition, the less likely that it will occur. Thus, you should spend more money on outcomes you most want to avoid" (Appendix 1). In addition to the above, we devised a "trade-off" table that forced patients to make choices between pain relief and common opioid-related side effects (nausea, vomiting, and pruritus). This table, derived from a group of expert obstetric anesthesiologists, allowed us to determine how parturients balance risk and benefit (Appendix 2). We gave subjects detailed written instructions to help them understand this "trade-off" table (Appendix 2). We asked research participants how much pain (visual analog pain scale [VAPS] 0–100 mm, with 0 = no pain and 100 = the worse imaginable pain) they would tolerate before exposing their baby to any analgesic medication they may receive. We instructed research participants to, "Indicate on a line below (mark with X) how much pain you would tolerate rather than expose your baby to any medication you receive." In addition, to determine the research participants' fear of regional anesthesia for their CS, we asked patients, "What is your biggest fear with spinal/epidural anesthesia? Pain on insertion/Failure to provide pain relief/Paralysis/Backache/Headache/Other (please specify)." An anesthesiologist involved in the study was available to answer any questions that arose while the survey was completed. Each question expressed only one idea (i.e., no questions contained "and") and no questions were phrased in a negative form. Surveys were returned in a sealed mailbox to maintain anonymity. At that time, parturients were given a similar survey form with a postage-paid envelope, addressed to the study investigator, to take home and complete after their CS. The post-CS survey was less detailed and consisted of the same priority ranking and relative value scales and trade-off table as well as a section for reporting any side effects the patient experienced during their CS. Parturients were instructed to complete the survey during the 3- to 5-day hospitalization period after their CS. To determine internal validity of the survey instrument, we analyzed the association (i.e., correlation) between the relative value data and the ranking data for each outcome. We also determined that the normal (or side-effect-free) outcome was ranked highest and had the lowest relative value assigned to it. We used descriptive statistics to summarize demographic and side-effect preference data. We used analyses of variance (ANOVA) followed by Dunnett's tests for multiple comparisons to evaluate the significance of both ranking and relative value outcome data. Pearson's correlation coefficients were used to calculate the correlation between the relative value data and the ranking data. ANOVAs were used to determine the effect of parity, education, household income, previous surgery or CS, and previous patient experience of a particular outcome on rank and relative value outcome data. We analyzed the data with SPSS (version 11) and Microsoft Excel using the appropriate statistical methods with P < 0.05 considered statistically significant. Back to Top | Article Outline Results Of the 100 pre-CS surveys distributed, 93 were returned. Eleven of the surveys returned were incomplete and excluded from data analysis. Overall, 82 surveys were analyzed for an 82% response rate. Demographics of the 82 pre-CS questionnaires are presented in Table 1. The study population comprised mainly married, highly educated, Caucasian subjects (Table 1). Seventy-seven percent of parturients had undergone a previous surgical procedure and 24% had undergone a previous CS. Of the patients surveyed, 57% had previously experienced at least 1 of the clinical outcomes studied. Only 23 parturients completed the post-CS survey and, of these, only 15 were complete enough to analyze. All 15 of these patients returning the post-CS survey had their CS under spinal anesthesia and experienced one or more side effects after their CS. Table 1 In the pre-CS survey sample, pain during CS was the least desirable outcome by both the ranking and the relative value scores methodology (P < 0.001) (Table 2). The mean ranking and relative value scores produced the same rank of clinical outcome (Table 2). Furthermore, the ranking and relative value outcome scores for each outcome were positively and significantly correlated (R2 ranged between 0.6–0.8 for the 9 outcome variables, P < 0.001) demonstrating good internal consistency. Of those surveyed, 49% ranked intraoperative pain as their most undesirable outcome. However, there was interindividual variability among the distribution of rankings of patients' preferences for anesthesia outcomes (Table 3). Although the majority (77%) of patients surveyed expected pain after their CS, postoperative pain was an important outcome ranking second after intraoperative pain (Table 2). Of those patients expecting pain after their CS, 71% expected some pain, 26% moderate pain, and 3% severe postoperative pain. However, despite such concerns, there was a reluctance by parturients to receive postpartum analgesics. Overall, patients would tolerate a visual analog pain score (0–100 mm) of 56 ± 22 rather than expose their baby to any pain medication they received after their CS. Table 2 Table 3 The post-CS survey had similar ranking and relative value score results, with pain during and after being the highest ranked, followed by vomiting, then nausea. Side effects such as shivering, cramping, itching, and sleepiness received similarly lower ratings as in the pre-CS survey. Parity, patient education, household income, previous surgery or CS, and previous patient experience of a particular side effect or outcome did not impact significantly on current preferences. There was no statistically significant correlation between previous CS, previous surgery, or parity with the outcomes measured. Possible paralysis was the principal fear with spinal and epidural anesthesia, expressed by >48% of patients surveyed. Failure to provide pain relief, headache, and pain on insertion were the principal fears in 17%, 15%, and 7% of patients, respectively. When patients were asked to select a pain medication dose (smallest, moderate, or largest) in order to trade off pain relief and a proportional increase in possible side effects, 60% of patients chose the moderate dose, 32% the largest dose, and only 8% the smallest dose. Similarly, the dose/side effect trade-off selection in the post-CS survey showed 46% preferred the moderate dose, 36% the larger-dose medication, and only 18% selected the smaller dose. Back to Top | Article Outline Discussion In this obstetric population study, we determined outcome preferences using both the ranking and the relative value scores methodology. Ranking and allocating monetary value to avoid unpleasant side effects have been used and validated in several previous studies (5,10–12). The current survey elicited data of patients' preferences for clinical outcomes with high correlation between the ranking and relative value scores. Our finding that pain during and after CS ranked highest among undesirable clinical outcomes is similar to those of several previous studies of general surgical patients (7–10). A study of 350 ambulatory surgery patients surveyed preoperatively using similar methodology found that pain was the leading concern (10). In a previous survey of 800 general surgical patients, pain was ranked the highest concern, with nausea viewed as only a moderate concern (7). Similarly, pain was found to be a more specific fear compared with nausea and vomiting in other studies of preoperative patients undergoing general surgery (7–10). Avoiding pain, rather than other side effects such as nausea, may seem to be an intuitive clinical end-point for anesthesia care providers. A panel of expert anesthesiologists considering which outcomes are most important to avoid, ranked incisional pain highest and above nausea and vomiting (1). However, avoiding postoperative nausea has been rated a primary concern in several survey studies in the general surgical population (4–6). In a previous survey at our institution, Macario et al. (5) used similar methodology in the general surgical population and found nausea and vomiting ranked as the least desirable outcome and primary concern. Similarly, Matthey et al. (6) found postoperative nausea and vomiting was of greater concern than pain in a survey of attitudes toward preoperative risks in the general population. A potential limitation of this study is that the sample of parturients surveyed at our institution was highly educated and older than the average parturient in the United States. The study population also comprised married, predominantly Caucasian subjects. Patients' preferences observed in our study may differ from other institutions and may not necessarily reflect national obstetric population preferences. Our patient population may not be typical of many obstetric units and this limitation may not allow other institutions with a less-educated patient base to extrapolate our findings to their practice. In addition, only approximately one-third of patients undergoing CS in our institution would have attended the prenatal classes, and patient preferences may differ within our institution between parturients attending and those not attending prenatal classes (class attendees tend to be higher educated than nonattendees). A similar population served by our institution was studied in a previous, methodologically similar survey in the general surgical population, so we believe that comparisons between the obstetric preference data and general surgical preference data are valid (5). Although we found that parity, previous surgery, and CS did not impact significantly on preferences, this study was not designed to determine the impact of these factors on preferences for clinical outcomes. More patients would be required in order to evaluate this relationship. However, the findings of poor correlation between previous experience of clinical outcomes is similar to other patient preference studies (5,9,10,13). Kindler et al. (9) found that young female patients with no previous or a negative experience had the highest anxiety scores before a surgical procedure. Women are more likely to express fear and anxiety for anesthesia outcomes (7,13) and are twice as likely to report any postoperative side effects and complications (14). Most of our women participants were of similar age and married, and thus differences in preferences with age and partner support could not be determined. Gan et al. (12) found a correlation between increasing age, income, and being married, and increased willingness to pay to avoid nausea and vomiting. Jenkins et al. (10) showed that older patients attributed less importance to adverse clinical outcomes. Because our research population consisted predominantly of highly educated individuals of higher socioeconomic standing, this did not allow us to explore the relationships among patient education, household income, and patient preferences. However, other studies have found that education and occupation did not markedly affect patients' concern for anesthesia (7,13). Physicians and patients may have different perspectives regarding treatment outcomes. Optimal management of acute pain often depends on patients' willingness to trade off pain control and treatment of side effects. In this study, the majority of parturients chose the moderate analgesic dose. This analgesic dose-selection table asked parturients to make a treatment decision similar to that of an anesthesiologist in trading off improved pain control with increased potential for side effects. Our findings are in keeping with an adaptive conjoint analysis of patients' preferences for acute pain that found pain and side effects had equal importance scores among patients (15). The post-CS survey produced similar results to our pre-CS survey. However, because of the poor response rate, findings and conclusions from the post-CS data should be guarded. The impact of the CS on our patients' preferences cannot be fully evaluated or adequately interpreted because of the small post-CS survey response rate. The small post-CS survey response rate was possibly attributable to many parturients not having undergone a CS. In addition, the long time interval between the pre- and post-CS survey and our reliance on participants to complete and mail their surveys to the study investigators after delivery of their baby may have contributed to the poor response rate. Almost half of the parturients surveyed expressed fear of paralysis as their principal fear with spinal or epidural anesthesia. This finding is higher than previously reported (7). Despite the extremely remote chance of this complication, this finding reinforces the notion that patients' fears should be addressed during the preoperative evaluation. Our study indicated that parturients are reluctant to receive postpartum analgesics because of the potential medication impact on their baby. Research participants reported they would tolerate moderate pain (VAPS 0–100 mm of 56 ± 22) rather than expose their baby to any pain medication they received after their CS. This finding illustrates the importance of patient education about breast-feeding and postoperative analgesics in this population. This study adds to our understanding of how patients value various clinical outcomes associated with anesthesia for CS. Adequate anesthesia and analgesia are clearly the most important outcome for the majority of obstetric patients compared with the general surgical population. However, maternal reluctance to receive analgesic medication for concern of transfer to her infant must be considered when prescribing postoperative analgesics. Findings from this study might help clinicians improve maternal satisfaction and CS anesthesia care by designing anesthesia regimens that most closely meet the individual patient's needs and expectations. Our findings emphasize the importance to patients of superior intra- and postoperative analgesia. Limiting the dose of bupivacaine in subarachnoid block as part of a "single-shot" technique for CS has been advocated with the goals of reducing the incidence of maternal hypotension, decreasing nausea, reducing time to discharge from the postanesthesia care unit, and improving maternal satisfaction (16–18). However, smaller intrathecal bupivacaine doses are also associated with intraoperative pain and late anesthetic failures (16,17). Whereas nausea and vomiting still ranked relatively high among our patients' concerns, pruritus and shivering caused only moderate concern. This information should be used to guide anesthetic choices, such as including spinal opioids in adequate doses to improve perioperative and postoperative analgesia despite a potential increase of pruritus and nausea.Back to Top | Article Outline Appendix 1 Priority Ranking and Relative Value Scales to Determine Preferences for Specific Anesthesia Outcomes and Potential Side Effects We want to determine your preferences for each of the following possible outcomes of anesthesia care (i.e., which ones you think are better or worse than the others). Please carefully read each of the following descriptions of outcomes you could experience as a result of your anesthesia and surgery. Assume that each situation described is equally likely and that each condition will last an equal length of time. First, rank each of these outcomes (you could experience any of these) in relation to each other from 1 to 10 from the most desirable (1) to the least desirable (10). Next, pretend that you are given $100 in order to prevent the following undesirable outcomes of anesthesia. Distribute the $100 such that the more money you spend on a condition, the less likely that it will occur. Thus, you should spend more money on outcomes you most want to avoid. Important: You must spend all of your $100 (and no more than that). You can choose to allocate $0 to only one of the outcomes described. Please note that many of these outcomes have been made to sound extreme to help you decide your priorities. Most people do not in fact usually experience multiple significant side effects with anesthesia. Treatment for pain or side effects is always available. Table Back to Top | Article Outline Appendix 2 "Trade-Off" Table When providing pain relief, anesthesia doctors may need to make treatment decisions that "trade off" relieving pain during and after cesarean delivery with a possible increased risk of side effects. Look at the table below and choose the pain medication dose (smallest, moderate, or largest) that best describes your preference for pain relief balanced with the possible risk of side effects during and after your surgery and anesthesia. This information will not be used to select the medication used in your current anesthetic. Select the desired PAIN MEDICATION DOSE: Smallest/Moderate/Largest (please circle). Table Back to Top | Article Outline References 1.Macario A, Weinger M, Truong P, Lee M. Which clinical anesthesia outcomes are both common and important to avoid? The perspective of a panel of expert anesthesiologists. Anesth Analg 1999;88:1085–91. Cited Here... | View Full Text | PubMed | CrossRef 2.Danis M, Mutran E, Garrett JM, et al. A prospective study of the impact of patient preferences on life-sustaining treatment and hospital cost. Crit Care Med 1996;24:1811–7. Cited Here... | View Full Text | PubMed | CrossRef 3.Shafer A, Fish MP, Gregg KM, et al. Preoperative anxiety and fear: a comparison of assessments by patients and anesthesia and surgery residents. Anesth Analg 1996;83:1285–91. Cited Here... | View Full Text | PubMed | CrossRef 4.van Wijk M, Smalhout B. A postoperative analysis of the patient's view of anaesthesia in a Netherlands' teaching hospital. Anaesthesia 1990;45:679–82. Cited Here... | PubMed | CrossRef 5.Macario A, Weinger M, Carney S, Kim A. Which clinical anesthesia outcomes are important to avoid? The perspective of patients. Anesth Analg 1999;89:652–8. Cited Here... | View Full Text | PubMed | CrossRef 6.Matthey P, Finucane BT, Finegan BA. The attitude of the general public towards preoperative assessment and risks associated with general anesthesia. Can J Anaesth 2001;48:333–9. Cited Here... | PubMed | CrossRef 7.Shevde K, Panagopoulos G. A survey of 800 patients' knowledge, attitudes, and concerns regarding anesthesia. Anesth Analg 1991;73:190–8. Cited Here... | View Full Text | PubMed | CrossRef 8.Meguiar RV, Wheeler AS. Lumbar sympathetic block with bupivacaine: analgesia for labor. Anesth Analg 1978;57:486–92. Cited Here... | View Full Text | PubMed | CrossRef 9.Kindler CH, Harms C, Amsler F, et al. The visual analog scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns. Anesth Analg 2000;90:706–12. Cited Here... | View Full Text | PubMed | CrossRef 10.Jenkins K, Grady D, Wong J, et al. Post-operative recovery: day surgery patients' preferences. Br J Anaesth 2001;86:272–4. Cited Here... | View Full Text | PubMed | CrossRef 11.Engloren M, Steffel C. Patient perception of monetary value to avoiding unpleasant side effects of anesthesia and surgery. J Clin Anesth 2000;12:388–91. Cited Here... | PubMed | CrossRef 12.Gan T, Sloan F, Dear Gde L, et al. How much are patients willing to pay to avoid postoperative nausea and vomiting? Anesth Analg 2001;92:393–400. Cited Here... | View Full Text | PubMed | CrossRef 13.Klafta JM, Roizen MF. Current understanding of patients' attitudes toward and preparation for anesthesia: a review. Anesth Analg 1996;83:1314–21. Cited Here... | View Full Text | PubMed | CrossRef 14.Myles PS, Hunt JO, Moloney JT. Postoperative 'minor' complications: comparison between men and women. Anaesthesia 1997;52:300–6. Cited Here... | View Full Text | PubMed | CrossRef 15.Gan TJ, Lubarsky DA, Flood EM, et al. Patient preferences for acute pain treatment. Br J Anaesth 2004;92:681–8. Cited Here... | View Full Text | PubMed | CrossRef 16.Ben-David B, Miller G, Gavriel R, Gurevitch A. Low-dose bupivacaine-fentanyl spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000;25:235–9. Cited Here... | PubMed | CrossRef 17.Choi DH, Ahn HJ, Kim MH. Bupivacaine-sparing effect of fentanyl in spinal anesthesia for cesarean delivery. Reg Anesth Pain Med 2000;25:240–5. Cited Here... | View Full Text | PubMed | CrossRef 18.Ginosar Y, Mirikatani E, Drover DR, et al. ED50 and ED95 of intrathecal hyperbaric bupivacaine coadministered with opioids for cesarean delivery. Anesthesiology 2004;100:676–82. Cited Here... | View Full Text | PubMed | CrossRef © 2005 International Anesthesia Research Society Article Outline Abstract Methods Results Discussion Appendix 1 Appendix 2 References Cited By Source Patient Preferences for Anesthesia Outcomes Associated with Cesarean Delivery Anesthesia & Analgesia101(4):1182-1187, October 2005. 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I really want to write a historical drama...
The first thing I tell all my students is be careful who you let influence your writing! Not all advice is created equal. And I guess your chat group are the only people on the planet who never saw the films The Imitation Game, Gladiator, or Brave Heart, or best of all, Shakespeare in Love. ALL historical movies, may I point out, and all major, major cinema hits.
That said, the writers of these screenplays did beat the odds, or the prejudice of the marketplace, if you prefer. Producers are the people who find the money to actually film the movie from your screenplay. And good producers are smart, film-savvy and pennywise, not pound-foolish. That's how you get bankrolled to green light another film – by paying attention to the bottom line.
The reason that period pieces or historical films put fear into the hearts of most producers is you can't just walk out the door and start shooting. You will need period specific costumes (ka-ching), period accurate locations (ka-ching) and often set design (ka-ching), and all kinds of specialty coaching for your actors (sword play, accents, horse-riding, (ka-ching, ka-ching, ka-ching). And all of this before you ever shoot a foot of film. Little wonder the mere mention of a historical script sends most producers screaming from the room.
But, back to the opening paragraph and those fantastic period piece films which all won rave reviews, I might add. The one thing they all had in common was a fantastic screenplay. Fantastic scripts make believers out of top-tier actors, who are always craving a part to really challenge them. And top-tier actors make believers out of tight-fisted producers and distributors.
So my advice to you, and any writer is always write what you LOVE. Write your period piece screenplay to the absolute best of your ability. Create a main character that every actress on the planet would kill to play. Create a story line and theme that is timeless, and your audience will not care that the lead actor wears a codpiece.
I hope this helps.And good luck with your screenplay. I can't wait to see it at the theatre


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According to the British Coffee Association, caffeine before a workout will make you more alert, improve your motor skills, give you renewed vigor, increase your output level and help you be more persistent. Plus you'll be able to perform 30% longer.
The caffeine reduces the chemical messages in your brain that normally induce fatigue and instead stimulates energy production and fat oxidation.
Having said that, there are also negative effects related to caffeine such as insomnia, anxiety, headaches, heart palpitations and high blood pressure.
So how much caffeine per day will keep you free from the negative effects?
Most health experts recommend that you have no more than 400 milligrams a day.
One cup of coffee contains approximately 100 mg so you should drink no more than 4 cups of coffee each day.
Mind you that's four cups of coffee if during your day you don't drink a soft drink (a 12 fl oz (368 g) has 29 mg of caffeine) or an energy drink (a Five Hour Energy Drink has 200 mg of caffeine; a 10 Hour Energy Shot has 422 mg of caffeine).
When it comes to coffee, you should drink coffee one hour before your morning or lunchtime exercise (if you exercise in the afternoon or evening, a coffee with lunch will suffice).
Note: It's recommended that pregnant women consume no more than 200 mg of caffeine per day (or about two cups of coffee).
Quote: - "I like coffee because it gives me the illusion that I might be awake." - Lewis Black


text: Last week I relaunched my website and brand identity. If you have been following along on social media you'll know that I set myself the challenge of completing my rebrand in 2 weeks. Today I'm going to share with you the behind the scenes process that went into creating my branding in the first week.


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Breakthrough Learning pilot programme demonstrates benefits of learning how to learn at a young age
Reading, UK, 12 March 2019 – Breakthrough Learning, a charity working with children to help develop their thinking skills, has just completed a pilot of its Smart Thinkers programme in partnership with Rainbows Montessori nursery in Burghfield. The Breakthrough Learning team worked closely with nursery staff to share strategies developed specifically to develop children's cognition through play using mediated learning.
Mediated learning uses human intervention (e.g. a teacher, parent, carer, peer - a mediator) to select, focus and organise information and stimuli for the benefit of a student. The approach enables students to learn new behaviour patterns and strategies that increase their ability to learn.
Vanessa Nichols, director, Breakthrough Learning explained, "Simply put, the brain is like a muscle and can be modified if 'exercised' and trained regularly and appropriately. By training the brain to use well-structured thought processes, students become more effective learners. Working with children at an early age helps to develop the core skills they need to support learning throughout their life. Skills include working systematically, problem solving, having clear understanding of a problem, understanding emotions and moderating behaviour. These are all essential skills to enable learning but are often overlooked in today's results-driven educational environment."
Rainbows Nursery staff involved in The Smart Thinkers trial were introduced to mediated learning techniques that will help the children develop key cognitive skills to accelerate their cognitive development and their ability to learn now and in the future.
Gillian Butler, owner of Rainbows Montessori Nursery said, "The Breakthrough Learning team asked us to think about why we do things and how we can extend the children's learning experiences every day. We found that we already used some mediated learning without really thinking about it. But when challenged by the team to think about set activities we were able to identify some important, new strategies that can really extend the children's learning. We really found the trial useful and I can honestly say, every parent and practitioner could benefit from the approach."
Joanne Jones, special needs co-ordinator, Rainbow's Montessori Nursery added, "Using the mediated learning technique has helped us to develop the children's learning experiences much more broadly. For example, learning to count is hugely important for children and an essential life skill. But learning to count can become easier for a child when they understand why it is important and how it can help them personally now and in the future. The mediation is very logical but takes some practice. I think it is easy to become focused on teaching children how count without the child really understanding why and where counting is useful."
After the success of The Smart Thinkers pilot programme, Breakthrough Learning is offering the Smart Thinkers training to parents and early years settings in West Berkshire. Anyone interested in the programme is invited to contact Breakthrough Learning at email@example.com or to visit their website for more information www.breakthroughlearning.org.uk.
Image caption: (left to right) - Joanne Jones Special Needs Co-ordinator, Rainbows; Vanessa Nichols, Director, Breakthrough Learning; Jill Butler, Owner, Rainbows
About Breakthrough Learning
Breakthrough Learning is a charity based in Berkshire/North Hampshire. Established in 2015, Breakthrough Learning teaches the vitally important, and often overlooked, skill of learning how to learn. The unique educational technique combines mediated learning and specially designed instruments in order to identify and enhance an individual's learning potential. As a result, the learner gains the knowledge and tools required to reach beyond their abilities.
Through mediated learning, students learn new behaviour patterns and strategies which improve their ability to think independently; process information; learn effectively and manage their emotions.
Global research projects demonstrate that mediated learning is an effective and powerful learning technique. Breakthrough Learning has undertaken its own trials to demonstrate the impact of Mediated Learn in partnership with Reading and Kingston Universities. The results will be published later in 2019.
For more information: www.breakthroughlearning.org.uk
About Rainbows Montessori Nursery
Rainbows Montessori Nursey is a privately-owned nursery which was established in September 1993. Located in the village of Burghfield Common on the outskirts of Reading, the nursery team believe children should be encouraged to become independent by learning how to choose their own activities and co-operate with others.
For more information: https://rainbowmontessorinursery.co.uk


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KUALA LUMPUR: Federal Territories Minister Khalid Samad says Putrajaya is considering a new piece of legislation dealing specifically with urban renewal, to facilitate the redevelopment of old buildings in the capital.
Khalid told the Dewan Rakyat today that there is currently no legislation for this in the country.
"To ensure an effective and implementable urban renewal process, the government will put forward a new piece of legislation," he said during ministerial question time today.
He was responding to Fong Kui Lun (PH-Bukit Bintang), who asked whether the ministry intends to introduce a new urban renewal law to facilitate the redevelopment of old buildings by private companies, similar to that in countries like Hong Kong and Singapore.
Khalid said the ministry had, through the Town and Country Planning Department, undertaken a study on guidelines for urban regeneration based on existing legal provisions under the Town and Country Planning Act 1976.
He said urban regeneration could be defined as a comprehensive and integrated long-term programme to address issues of economic slowdown, physical dilapidation, abandonment as well as brownfield and non-economical areas.
This is streamlined with the government's vision and development policies which can be implemented by either the government or private sector, he added.
"There are four categories under the guidelines, namely urban redevelopment, urban rehabilitation, urban preservation and urban revitalisation.
"However, in the Malaysian context, there is no legislation towards this end," he said.
Fong said many old buildings are not redeveloped as ownership is held by different people, which hampers urban renewal.
Khalid said this was a problem in other countries as well, not just Malaysia.
He gave the example of Singapore, where buildings below 10 years old only need the agreement of 90% of the owners while for buildings over 10 years old, only 80% is needed.
"In Malaysia, we need agreement from all owners. We will address this issue in the legislation we plan to introduce," he said.


text:
Search Results for 'home winger'
4 results found.
Buccaneers fall short in opening AIL fixture
Buccaneers 13 Naas 36
Terenure leave it late to snatch away victory
Wait over as Buccs record first league win
Buccaneers finally found the winning formula as they forged their first victory in the Ulster Bank League this season, holding off the challenge of University College Dublin (UCD) to emerge with a 19-13 win at Dubarry Park last Saturday.
Buccs Seconds make short work of Galwegians
Buccaneers 29 0 Galwegians


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A Sketch of a Young Woman in Five Parts
They sat quietly across from each other in the busy restaurant. She was a pale, thin little girl with short, dark hair. She played absently with her food, deep inside of herself, making pretend with her potatoes and chunks of mangled broccoli. Her mother sat across from her, she was pretty and had long blonde hair and a pair of sunglasses turned up on the top of her head.Read More


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Shrivel: 05.01.2019 in 17:36
Good zoom in on nice tits
Wdburns: 08.01.2019 in 08:35 from Monaco
I've talked to a couple of close friends, and they said that this is a HUGE red flag...as we've been together for a long time...and for her to say something like this is not good.
Adamsco: 01.01.2019 in 17:34
Laughter is usually a good sign.
Quina: 02.01.2019 in 09:02
Neon clothes just show off a girl's tan so well, love it.
Benjy: 30.12.2018 in 06:28
keeper! shes a cutie
Paddles: 08.01.2019 in 18:01 from Monaco
very honest and looking for the real woma.
Spiking: 31.12.2018 in 23:21 from Monaco city
Snifty: 30.12.2018 in 04:57
We were broken up for only a little more than a month, and I was so depressed that I could barely function. I threw up every time I ate; I couldn't sleep; I lost weight and cried constantly. I missed him horribly. I couldn't believe my relationship, as imperfect as it was, was over, and I couldn't stop thinking of him as my best friend and boyfriend.
Crinite: 06.01.2019 in 07:15
They don't really know what it mean and are most likely immature
Kricker: 07.01.2019 in 03:03
I am mentioning this because it very well may not be an excuse when he says stuff like In the beginning we were happy go lucky was because we didn't have anything to worry about, it was like a vacation for us. Now that we're worried about money and jobs, it's differentIt may be an indication that he is feeling some of the feelings I had. Especially if you two really did start your relationship during a "vacation" like period for either of you. Regardless it doesn't sound like this guy is treating you well at all, I think the above posters have given some great advice. Ask him point blank how he is feeling about you and try to talk to family or friends you have back home about maybe helping you get home if that is what needs to happen.
Elgin: 05.01.2019 in 02:12 from Monaco city
We go into a debate about beauty. He told me that when he is, say, walking around in a mall he notices all of the people around him. He is a very observant person. He said that if a woman walks by who is attractive he will notice. He said that he will take more note of her if he finds her to be beautiful, but explained that he wouldn't do so if I was around. He claims that this habit of taking more notice is the same for a beautiful child or even man (how many men does he really find beautiful, please). He said that when something is pleasing to his eye, be it a sunset or a baby, he will take notice and a beautiful woman falls into this category. He went on to say that he thanks God for these beautiful sights because he is happy that their beauty can exist in an ugly world.
Attaboy: 05.01.2019 in 01:02 from Monaco
"Met Shams tonight at her hotel in Deria. She is my first Arab escort ever, I can say I have enjoyed my short visit with her. She has superb tricks to make you horny. She is tight and good jelly breasts.
Obsse is available also for Escort for Couples, Monaco city all service sex with condomRates: or Dominance Light. For more information, please ask Obsse by sending a private message.
She takes off her sheriffs clothing, including denim shorts and shows her hairy body. Her lingerie slides across her hairy body and she strips naked to strip naked on her bed. Amara Ranipas legs wide open.
Big Tits Blonde Milf. Sexy Lucia is in a hot black dress, and she shows off her hairy pits which makes her sexier.


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I have been asked to interview as a software developer at an e-commerce company. As I am very interested in test automation and continuous integration / continuous delivery I have set systems up for this at both my current and previous company, with partial success.
The new company doesn't currently have any test automation, which is something of a red flag to me. However in the initial phone interview I was assured that this is something that the company would wanted and it wouldn't be a problem for me to act as a strong advocate for CI/CD and XP technical practices if I was to be offered and take the job.
This question is about how I could protect myself from the risk of having to work in software team without these thing, where there never quite seems to the the time to set them up. During the interview, would it be a good idea to ask the management to make a written statement like the following and circulate it within the company as a condition of me taking the job:
Company **** recognises the importance of test automation as part of a continuous integration / continuous delivery process to get software features to market in a timely and reliable manner.
We also recognise that it is a problem that our software is not currently able to test itself.
Therefore, we encourage each in house developer to work on building and improving test automation and software delivery systems, to the extent that they feel their doing such work is in the interest of the company. The company undertakes not restrict the time any developer may spend on such work to less than 20% of their working hours in each week between now and April 2019.
This applies to current developers and any who join the company during this period.


text:
Energy Matters Acupuncture & Qigong
4341 Piedmont Ave., 2nd Floor, Oakland, CA, 94611
Our Qigong Room is 500 square feet of beautiful, open space with bamboo floor, ideal for movement classes, sound healing classes, lectures or workshops. Located in our peaceful healing center, the studio is private, quiet and well-lit with lovely, natural light coming from a full wall of windows. This handicap accessible 2nd floor facility with elevator, serves as a home to our on-going Wild Goose Qigong classes and health-oriented workshops.
The studio is located at near the northeast end of Piedmont and Pleasant Valley Avenues. We are walking distance from Piedmont's grand variety of shops and restaurants.More info


text:
Subtotal: ( items in your basket)
You Save: £2.51
Sold out
Average connection time 25 secs
Average connection time 25 secs
The Sweet Dreams Grey Star Rug from Sass & Belle is perfect for a nursery or child's bedroom. Crafted from 100% cotton, the pale grey star-shaped rug is detailed with a sleepy face with pink cheeks. The super cute, delightfully soft rug will add a beautiful accent to your child's room.
Dimensions: H: 70cm x W: 67cm
There are currently no reviews.
Write a review to be in with a chance of winning a £100 voucher.


text:
Prime Freedom Park
Land for sale in Embilipitiya
- Embilipitiya Kolabage Ara
- 65,000 LKR Per Perch Upwards
- Available for Reservation
Land Details
Situated in the Low facilities area for a better living also locating in a calm environment. 1.5Km to Embilipitiya - Rathnapura Road 1.5 Km to Udawalawa Junction.
- Three Phase Electricity
- Pipe Bon Water
- 20' to 30' wide road
- Provided
- Embilipitiya
- Payment Can be done without interest Within Six Month,Payment Can be done in Installment,Bank loan facilities
Investment Details
After reserving by paying 25,000/= and completing the down payment you can pay the balance in installments or in a bank loan
Contact our Agents for more Information
call : (+94)112699822
call : 0713404040
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text: Fox Farm Showing all 3 results Default sorting Sort by popularity Sort by average rating Sort by newness Sort by price: low to high Sort by price: high to low Sort by Sales Rank (2) Foxfarm FX14000 Ocean Forest Organic Potting Soil Bags 6.3-6.8 pH | 3 Cu Ft $59.94 Add to cart Sale! FoxFarm FX14053 12-Quart Ocean Forest Organic Potting Soil $15.99 $6.03 Add to cart Sale! FoxFarm FX14079 Ocean Forest Soil Bag, 1.5 cu. ft. $19.99 $17.79 Add to cart


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hmlCAROL SWEATSHIRT
Stretch jersey top
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Choose size
- Free shipping on orders above 120€
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The hmlCAROLINE T-SHIRT S/S is made in a stretch jersey with an all-over rib effect. This hummel® top hugs your body and provides the perfect blank canvas to build upon – add a sweatshirt, add a zip jacket, add a coat! The cropped sleeves and the turtle neck also create a stylish silhouette all by themselves.
Item no.. 205157-9001


text:
Well here we are, Nature's in-between, as when the clothes are picked up off the floor but the bed still isn't made. It snowed last night but more than a few trees are clutching their pale yellow … [Read more...]
Birth or Death?
TEXT FOR PREACHING Isaiah 64:1-9 Oh, that you would rip open the heavens and descend, make the mountains shudder at your presence— As when a forest catches fire, as when fire makes a pot to … [Read more...]


text: Jockey Abimael Medina notched the first win of his career Friday at Gulfstream Park while guiding Sir Hannoun ($4.40) to a decisive victory in the fifth race. A native of Trujillo Alto, Puerto Rico, the 10-pound apprentice moved to South Florida and learned his trade at Gulfstream Park West. "The trainer told me I was […]Continue reading


text:
Stories By Pete Weintraub
/ 2 years ago
The Winner's Morning Ritual
Start your day right. What do I mean by that? Let me explain… As entrepreneurs, our business is our baby. It's...
/ 2 years ago
Put Yourself FIRST!
As entrepreneurs, we often treat our businesses as the most important thing in our lives. We get up early, we stay...
Lifestyle Ideas


text:
T-Mobile disrupts the mobile industry…and the holidays. Our social video series became the brand's most engaged content on Facebook and Instagram during the 2015 holiday season.
We made an carousel tell a story on Instagram. Our efforts led to Instagram creating a case study of our campaign as an example of best-in-class creative effectiveness. Our simple story about international calling used carousel scrolling to our advantage, lifting recall by 24%.
And our ultra-fast shoot took us from Vancouver to Seattle to Puerto Vallarta in three days, and published in less than a week from concept.
It's not sports unless someone loses. During the 2015 World Series, we let Major League Baseball fans run wild in these videos featured on Facebook and Instagram. And yes, we really shaved a logo into that dude's head.


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text:
Dear Mr. Popham,
In my 37 years as a Realtor in South Florida, I have had the opportunity to work with many, many agents, but my recent experience with your Luis Alvarez was one of the best.
I placed a new listing in the MLS and immediately, Luis showed the property, and quickly brought a very good offer. Within two days the contract was fully executed. The transaction went well, until I became seriously ill and ended up in the hospital for a week. Also, coming home, I was still ill and unable to work at all. During this time, Luis took over the entire transaction and complete what needed to be done. He was able to negotiate many last minute inspections problems, so that all parties were content with the results, kept the seller and buyers informed as to every aspect of the transaction, completed the final walk-through, and when the property closed, both the buyer and seller sent blessings to each other.
I am most appreciative to Luis for all of the extra work he did to bring this transaction to a successful closing. He also continued to phone me, to keep up on my health progress, and even sent me the gift of flowers. He is a real gentleman and a valuable agent to your firm.
Again, thank you Luis, I do hope we work together again someday.
Donna Maxwell, Broker Associate
Cutting Edge Investments and Realty
Luis, was introduce to me from a close friend, I had never met him before. From the first day we spoke he was pleasant, asked the right questions, and was never pushy or annoying in anyway. He gave me the impression of an honest guy whom enjoyed his work and looks forward to assisting us the client in finding that the we all value so much, our home.
Luis was very patient we looked for over six month, he never gave up on me, again always pleasant and a true professional. End result, I was able to find a home which am very happy with and made a friend in the process.
I will highly recommend Luis to my family and friends in my view he learned my requirements and did not wasted time, he screened the available inventory and only sent me those that would fit my criteria. This eliminated loss of time and effort.
Luis on behalf of my family and I thank you for all your help and support. We love our house!!!!
Mr. Luis Alvarez did an excellent job in searching for the property after understanding my home buying needs. He also served as a good liaison and provided needed guidance along the way until closing. I will recommend him to any future home buyer. We love our new home in Pembroke Pines, FL !
Luis Alvarez was a pleasure to work with. His professionalism was outstanding. From the moment I signed the contract he was in daily contact with me. Due to his diligence in advertising and opening the house to show realtors and prospective buyers, the house was sold within a month. I would hire Luis again without hesitation and will recommend him to anyone I know who might need a realtor.
We were fortunate enough to have met Luis by chance. Having been through four moves in the past five years and coming across a couple dozen realtors; Luis was second to none. From the initial contact, he was professional, attentive, patient, and willing to help.
Luis is passionate about Real Estate and it was transparent from day one. He quickly became like family to us with the manner we were treated from beginning to end, and beyond.
Luis is the best in the industry!
Luis went above and beyond any of my expectations. Not only getting to know me - end to end- provided that I fall in love with the first home Luis showed me. It was perfect! The overall experience was phenomenal
Our relationship with Luis started 4 years ago during which we rented a condo, bought a condo, sold a condo and subsequently and finally bought a house all with his council and help. Through it all he had our best interest at heart and had our complete trust. He knows the South Florida market really well and his assessment have always been accurate.
A great guy with a ton of friends in different professions; mortgage broker, contractors , roofer even landscapers. You name it he has it. So even after the deal goes through he will be there for you trying to help you out in any way he can. A true gentleman and friend. God bless him.
Luis Alvarez is the best realtor I have ever used in all my experience of selling homes. He totally removes the many difficulties often seen with inexperienced or overloaded realtors.
Selling my home with Luis was very easy and seamless. I only wish we could take him to Wisconsin with us to help purchase our next one! You will not regret choosing Luis to handle all your real estate affairs.
It is my true pleasure to have someone such as Luis Alvarez act as my real estate agent. From the onset of contract negotiations through consummation of the closing of every transaction, Luis handles every aspect of the process with the utmost professionalism. In fact, he goes beyond the call of duty by adding a distinct personal touch to his marketing techniques, which truly makes a significant difference in whether a sale occurs or fails. Consequently, those relentless efforts on his part make deals close. Whether you want to sell or buy (residential or commercial real estate), your opportunity for success will inevitably be enhanced if you engage Luis to assist you in such an endeavor.
Luis & Ana Alvarez were able to sell my father's long-time Coral Gables home which had sat unoccupied and contracted mold for a very fair price. This was a very difficult sale which he never gave up on and consequently my life partner asked that he sell a one acre rental property he owned in South Miami. As a courtesy to our long-term tenant we stipulated that we would give Luis the contract as long as he would agree to clear all showing before hand with the tenant and not hold open houses.In less than one week we had a very good offer on the table but Luis was committed to insure we received top dollar for this property and did not push for a fast sale but opted recommending to wait for the sale he was convinced would be the highest we would be able to get for this property. Luis professinally presented all offers but never wavered from this resolved.Within a short couple of months he succeeded in successfully closing an all cash deal and personally oversaw that everything was handled properly and efficiently for us, our tenant and the new buyer. Luis remained personally involved long after his commission was earned. We have him currently searching for a commercial property for our business not only does he know the real estate market well but he also knows how to search for the right fit for you. His knowledge,character and integrity allowed us to close both deals with ease.
When I started looking for an investment property in South Florida, I was more than a little inexperienced. A phone call to Luis Alvarez solved that problem. Luis was courteous and extremely knowledgeable. He took me to one property after another, offering all the information I needed to make a decision. When I decided to make an offer on a property he expertly guided me through the process. The real estate market was going through a difficult period, and I benefited immensely from Luis' experience and competence. I wholeheartedly recommend him.
I am pleased to share what a wonderful experience it has been working with Ana & Luis Alvarez. Hands down AMAZING REAL ESTATE SERVICE! "Nothing like working with an honest, professional and hard working team! What I appreciate the most is their personalized service and ability to adjust to the client needs"
I have had the pleasure of working with Luis over the past 12 years and I can honestly say that not only is he a true professional but he has always gone above and beyond the call of duty. His dedication and hard work always produced favorably. We hired Luis to sell our Cocoplum home in 2013 and he provided us with top money for our home and peace of mind throughout the process. I have often recommended Luis to my friends and colleagues and know that he would always put forth 100%!
Three words come to mind when I think of Luis Alvarez. Thorough, aggressive and responsive. I first met Luis many years ago when he was working with BMW. He was the most ethical and responsive person I had ever dealt with. I later discovered that he had gone into real estate and when I was interested in buying an investment property I, without hesitation, contacted Luis to represent us. Luis showed us numerous properties and did not hesitate to steer us away from properties that he believed did not meet our needs. The property that we finally purchased has been a great income investment and has appreciated over 50% in three years.Luis was responsible for our decision to purchase the property.I cannot say enough about the professional way that Luis conducts business and would highly recommend him to anyone in the market looking to buy or sell a property.
It is my honor and privilege to recommend Luis and Ana as our realtors. I am not a financial advisor nor do I engage on mutual business with Luis, Ana, or associates. Luis became our Realtor several years ago. We were in search for our dream home and had gone through five other realtors and nearly 10 months of fruitless search. We met Luis at a home we visited and he happen to be the listing agent for that property from that day on he became our realtor, but also a dear friend. Luis seemed to have endless patience, especially since we always seemed to find something wrong with all the houses we visited. I guess that's normal when you are looking for that dream home for your family! After many months of searching and looking at 3-5 homes per week, we found our dream home, we knew it from the moment we walked in. We made an offer that same day and reached an agreement immediately with the seller thanks to Luis's efforts and expertise in negotiations. We later hired Luis again to sell our other home which he did within10 days and he got us top money with a cash buyer. I can't say enough about Luis and Ana. They are amazing!!
"Choosing Luis as a realtor was a great choice. We have had very good experiences selling two properties and finding our new dream home. Luis is a true professional with extensive knowledge of the Miami market, great negotiating skills and excellent follow through and attention to detail. If you want someone to advocate for you and your best interests as a buyer or seller, look no further than Luis."
It is with pleasure and gratitude that we share comments on our experience with Luis Alvarez in the listing and sale of our home in 2009 and the purchase of another home in 2010. While we have bought and sold a number of houses, we have never before encountered such a level of excellence. The experience at each phase of the sales and purchase effort was superior, such as innovative efforts in developing prospects, useful insights on pre-listing renovations/staging, effective showings and proactive facilitation during the sale negotiations/due diligence. All of these tasks, whether business-related or interpersonal, were accomplished with a noticeable degree of competence, humility, integrity, grace and professionalism. Thus, we highly recommend Luis Alvarez for all your real estate needs.
I met Luis some years ago but never thought I would need his services one day. About two years ago, I was left with a small home in Hialeah and didn't know whether to rent or sell it. I consulted Luis and he met me the same day. He did extensive research and showed me why selling would be in my best interest. As a result, we listed the home at a high price for the existing market. In one week I had an offer at full price. As expected, there were complications with the city of Hialeah and the bank that was approving the loan. Luis made several trips to the home and met with the city and new owners. The issues were quickly resolved and I was able to close. I would highly recommend Luis. He is very professional, a great negotiator and looks out for your best interest.
How can I begin to describe Luis, I really would run out of positive adjectives doing so. Well, when I decided to put my house for sale Luis was highly recommended by a friend. I must say that he exceeded my expectations to that recommendation. From the very beginning, he was a pleasure to work with. He was reliable, organized, thorough, and always presented himself in a professional manner. I was impressed with his knowledge of the real estate market and its competitive landscape. In addition to this, and most importantly, he showed remarkable integrity and honesty, with that being said it was easy to trust his guidance. Furthermore, Luis did not only sell my house but helped me find another place to call home at a great price! Overall, I absolutely recommend Luis Alvarez as a great real estate professional to anyone who is considering a real estate transaction in South Florida.
Luis was extremely professional throughout the home finding process. He visited EVERY SINGLE home with us and gave us great insight on each property. If you work with him, you will be VERY pleased and appreciative of his hard work.
I want to take a moment to thank you for helping me find our home. I truly appreciate all the hard work your patience, professionalism, and most of all making the experience seem easy from beginning to end. I will gladly refer others to you because I can say with certainty their experience will be a great one! Again, thank you for all your help.
Luis is amazing! After our mother passed away, my brother and I called him (on a Friday) to handle the sale of her condo. By the next day, (Saturday), Luis had already scheduled two showings Monday morning. He called again Sunday afternoon to cancel the showings. It seems he had a signed contract in hand - a cash offer 30% above our original asking price. Luis is truly AMAZING!!
"Working with Luis Alvarez all these years has been a truly great experience. He has handled both commercial and residential property sales and purchases for our business group and my family. His professionalism and knowledge of the area are outstanding and he continues to be my personal real estate agent. If you need additional information, please do not hesitate to call me."
The best decision I made in selling my home is giving the listing to Ana and Luis Alvarez. Even though my home was turnkey and was in mint condition, they made it more appealing. The photos they took on the outside and inside were came out like they were taken by a professional photographer. My home looked like it belong in an exclusive parts of S. Fla. They held two "Open Houses" in a gated community that was attended by dozens of people in both events. The end result my home was sold in less than two months. Furthermore it was sold for the highest price in the zip code since 2009, thanks to the hard work Luis and Ana performed. My neighbors at that time were wondering if we were having a party, that's how many people came by the open house. My most sincere thanks to Luis and Ana for their hard work and dedication to excellence!
The professional and personal service received from Luis Alvarez by helping us buying a property for our daughters and latter in selling our home, was unique and outstanding. I always recommend him to our friends.
"We are very pleased to share what a wonderful experience it has been working with Luis& Ana. It would be a challenge to be concise in describing everything that he has done for our family. Luis has the unique ability of making you feel as if you are his only client. He is a true professional who cares very much for his clients and delivers on everything he commits to. Luis assisted us in selling our home for top dollar and purchasing our forever home at an incredible price. He made possible the impossible. In addition Luis helped us find and purchase our own office condo. In doing so he has improved beyond measure our professional economic standing and situation. They helped us to secure our personal and professional future. We highly recommend Luis and look forward to working with him again in the future. He is a fantastic real estate agent and an even a better friend."
When we listed our house with Luis, were quickly impressed with his market knowledge, and recommendations on preparing the property for sale. Luis did an extensive market analysis and helped us set a reasonable price that would be attractive to buyers, while at the same time, maximize our return. The "buzz" was instant, with his barrage of online and print ads, and we had immediate showings. Finding the right buyer, and working the deal were Luis's forte. Without a doubt, we could not have sold the house faster, or for a better value without his expertise and tenacity.
First and foremost Giselle and I would like to thank you for your professionalism, knowledge and more importantly patience. As a first time home buyer purchasing a home can get overwhelming but your confidence was contagious which secured our doubts. Today we live in our beautiful dream home in Palmetto Bay and couldn't be more thankful to you.
Mr.& Mrs. Alvarez sold our home February 2014. I was able to sell the home fast and within 10k of my asking price. Mr Alvarez was very professional, prompt with all appointments to show the home, advertised our home in the Miami Herald numerous times and was helpful in every way possible from the moment we listed the home right through inspection, walk through and closing. We highly recommend them both to sell your home or if you are looking to buy a property as we will be doing that very shortly with them. Sincerely, Julio and Daisy Llanes
We had a lot of apprehension when we decided to sell our home of 20+ years. We entrusted the sale of our home to Luis, during the last down turn of the market. Additionally, we had an urgency to move the property quickly, since we had purchase another current residence. Luis work diligently and brought us multiple offers within a very short period of time. The deal was consummated, in a very seamless manner, with a very solid buyer. Luis professional approach and knowledge of the real estate market puts him in a class by himself.
Luis is a true gentleman. He is honest, dependable and extremely punctual. He won't give up until he makes sure you find what you are looking for. His nice demeanor and personality are truly refreshing. What are you waiting for? Call him! You won't regret it.
Ana is fantastic... I am going to use her expertise on my next buy.
Best Real estate agent in Miami always willing to go the extra mile for her clients.
To all customers, Kay and I are both realtors, and when the time came to sell our home the choice was simple Luis Alvarez . To our complete satisfaction, Luis Alvarez handled the listing, sale and closing of our residence in a very professional manner with expertise. The experience was relaxing and he put all our concerns and worries out of our minds. If you are seeking quick and positive results, then we highly recommend Luis Alvarez as your real estate representative. You will not be disappointed.
I worked in Univision for 17yrs and every time we had a celebrity relocating to Miami I would always contact Ana Maza & Luis Alvarez as the realtors of choice. A very professional team, very reliable and of thehighest integrity. The Alvarez team discretion and knowledge of the Real Estate Market puts them years ahead of their competition!
Great job Luis and Ana. You sold my home in less than 30 days and for so much more that I expected! You guys are AMAZING! Best realtors I have ever met, what a TEAM!!!!!
Real Estate Never Sleeps...and Ana works tirelessly to find her clients the best deals the market has to offer!! Highly recommended.
Great Real Estate Team! They know their market and what their clients want.
I just want to say "THANK YOU" once again for all your help and hard work in selling my house! It went great and much faster than I ever expected. I know that was due to your great professionalism and hard work. I truly appreciate all the interest you took in doing what was best for me and guiding me through the whole process.Thank you, thank you, thank you!!!! You are definitely on my referral list!
"Ana sells Real Estate like cinnamon rolls out of the oven!!"
Hands down the "BEST" Real Estate Service …where reliability and intergrity meets professionalism!
Here are a few reasons why I'm appreciative this Holiday Season...Luis is a very professional seasoned realtor who works diligently for his clients, extending far and beyond our expectations with exceptional service and results, Luis sold our home in one week! He is very committed, dependable, friendly, creative and patient, we highly recommend him when selling your home. Luis is an excellent choice! A true gem in Real Estate Sales!!
I want you to know how much we love our house! Thanks for helping us make it happen. Still fixing and arranging, LOVING EVERY MINUTE,THANKYOU!
As you may recall, you helped use sell a townhouse in a gated community at Casa Del Sol. We had recently purchased this property as an investment with the intentions of being landlords We listed the property with a realtor and after eight months the realtor found a client to rent our property .Then we listed this property for sale and we were extremely fortunate to have found you. As our agent and becoming our friend you turned out to be the best, most qualified realtor we could have hoped for, you guided us through the sale process telling us how to make our property saleable with numerous tips and suggestions that in our words sold our slow moving property. Your experience and enthusiasm were instrumental in the sale of thisproperty!
Luis Alvarez , Luxury Real Estate Specialist
Jeanne Baker International Realty Inc
11921 S. Dixie Hwy Suite # 209
Pinecrest, FL 33156
P. 786-942-7712 Direct


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Blog - Spas in Naples FL
Call Now: 999-999-xxxxLike (0) Back to Results
* Please note - the site does not imply awareness and / or provide and / or advertise sexual services !!!
Spas in Naples, FL- Offers a variety of massages
When you go for an exotic holiday one thing that is mandatory on your list is to experience massage. Lots of hotels in Florida offer the Spa services to their guests. After a hectic day excursion, you want to relax your limbs; touch therapy works in relieving the tiredness and stresses of the body. One does require massages in daily routine too. It is advised to get a massage done once in a while to keep the blood circulation active. When you are tired or stressed you want a miracle to relieve you. The healing touch of masseur brings your energy back. Now, when you decide that you want to visit a massage center, you should make your appointment in advance so that you don't have to wait as a massage takes an hour or more so you may not manage to get a walk-in appointment.
Spas in Naples, Fl offer treatment massages; these massages are for relaxation and at certain places for weight loss too.
You need to decide on what kind of massage you want if you wish to get a therapeutic massage or essential oils massage. There are separate massage centers that provide only massage services and no other beauty treatments. One needs to make sure that the center you are visiting is neat and clean and the staff is well trained. A trained therapist will be able to provide you overall satisfaction. Usually, the Spas have nice aroma in the air with the essential oil, this kind of ambiance is helpful in relieving stress and bring peace to mind. The essential oils massage centers give a sophisticated and stylish look.
The masseurs interact with the clients to know their preference of aroma, the pattern of massage. The massage room is lit with aroma candles, and light, soothing music plays in the background. The masseur gives a massage in sync with the music. It is a mesmerizing experience which leaves you relaxed and lighter. Many clients also prefer getting an erotic massage in Naples, Florida.
The massage centers generally provide an effortless look, and they use oils with herbs in them, the whole atmosphere is filled with the fragrance of herbs, and some people don't like this fragrance much as it is very strong. These are usually run by a person who is qualified in massage therapy, as they recommend some herbal medicines too to be taken along with therapies.
Client #: 2995


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Posted by Steve Price on June 16, 1999 at 04:22:47:
In Reply to: Prediction of Collectibles? - The relation between antique and aesthetic posted by Erol Abit on June 16, 1999 at 02:29:52:
Dear Erol,
1. You are absolutely correct in saying that making a prediction perturbs the system and affects the outcome. This does not destroy the usefulnes of the prediction, although it reduces its accuracy somewhat. It would be flattering to believe that our website is so important that we can seriously influence collectors 50 years from now, but I don't think this is possible.
2. The relation between aesthetics and a piece's age is a statistical one. If, out of every 1000 antique pieces, 950 have been destroyed and 50 have been preserved, then that 50 will almost surely have better aesthetic properties, on the average, than the original 1000. No such selection has yet occurred in the population of new rugs.
3. We recently held a Salon about why collectors collect what they do. There was agreement that aesthetics is important, perhaps the most important element, but that was certainly not the only factor.
Steve Price
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my first knitted dungarees and bodysuit set
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my first knitted dungarees and bodysuit set is rated out of 5 by 4.
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Date published: 2018-10-06
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