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External validation of the QCovid risk prediction algorithm for risk of COVID-19 hospitalisation and mortality in adults: national validation cohort study in Scotland
Respiratory epidemiology
http://orcid.org/0000-0002-5194-8083Colin R Simpson1,2,
Chris Robertson3,
http://orcid.org/0000-0002-3643-7859Steven Kerr2,
http://orcid.org/0000-0002-4101-4535Ting Shi2,
Eleftheria Vasileiou2,
Emily Moore4,
Colin McCowan5,
Utkarsh Agrawal5,
Annemarie Docherty2,
Rachel Mulholland2,
Josie Murray6,
Lewis Duthie Ritchie7,
Jim McMenamin6,
Julia Hippisley-Cox8,
Aziz Sheikh2
1School of Health, Victoria University of Wellington, Wellington, New Zealand
2Usher Institute, The University of Edinburgh, Edinburgh, UK
3Department of Mathematics and Statistics, University of Strathclyde, Glasgow, UK
4Information Services Division, Public Health Scotland, Edinburgh, UK
5School of Medicine, University of St Andrews, St Andrews, UK
6Health Protection Scotland, Public Health Scotland, Glasgow, UK
7Academic Primary Care, University of Aberdeen, Aberdeen, UK
8Primary Care Health Sciences, University of Oxford, Oxford, UK
Correspondence to Professor Colin R Simpson, School of Health, Victoria University of Wellington, Wellington, New Zealand; colin.simpson{at}vuw.ac.nz
Background The QCovid algorithm is a risk prediction tool that can be used to stratify individuals by risk of COVID-19 hospitalisation and mortality. Version 1 of the algorithm was trained using data covering 10.5 million patients in England in the period 24 January 2020 to 30 April 2020. We carried out an external validation of version 1 of the QCovid algorithm in Scotland.
Methods We established a national COVID-19 data platform using individual level data for the population of Scotland (5.4 million residents). Primary care data were linked to reverse-transcription PCR (RT-PCR) virology testing, hospitalisation and mortality data. We assessed the performance of the QCovid algorithm in predicting COVID-19 hospitalisations and deaths in our dataset for two time periods matching the original study: 1 March 2020 to 30 April 2020, and 1 May 2020 to 30 June 2020.
Results Our dataset comprised 5 384 819 individuals, representing 99% of the estimated population (5 463 300) resident in Scotland in 2020. The algorithm showed good calibration in the first period, but systematic overestimation of risk in the second period, prior to temporal recalibration. Harrell's C for deaths in females and males in the first period was 0.95 (95% CI 0.94 to 0.95) and 0.93 (95% CI 0.92 to 0.93), respectively. Harrell's C for hospitalisations in females and males in the first period was 0.81 (95% CI 0.80 to 0.82) and 0.82 (95% CI 0.81 to 0.82), respectively.
Conclusions Version 1 of the QCovid algorithm showed high levels of discrimination in predicting the risk of COVID-19 hospitalisations and deaths in adults resident in Scotland for the original two time periods studied, but is likely to need ongoing recalibration prospectively.
All code, metadata and documentation for this project is publicly available at https://github.com/EAVE-II/Qcovid-validation. A data dictionary is available at https://github.com/EAVE-II/EAVE-II-data-dictionary. Most of the data that were used in this study are highly sensitive and will not be made available publicly.
http://dx.doi.org/10.1136/thoraxjnl-2021-217580
What is the key question?
Does the QCovid algorithm accurately predict the risk of COVID-19 hospitalisation and death in Scotland?
What is the bottom line?
The algorithm performed well according to a number of metrics we evaluated.
Why read on?
It is important to validate the QCovid risk prediction algorithm because it is being used in the UK to inform shielding and vaccine prioritisation policies.
In December 2019, a novel coronavirus (SARS-CoV-2) emerged in Wuhan, China.1 WHO declared the outbreak a public health emergency of international concern on 30 January 2020, and then a pandemic on 11 March 2020. As of 15 September 2021, WHO has reported more than 225 million confirmed cases globally and over 4.6 million deaths.1
Rapid, large-scale observational epidemiological studies have been used to identify the characteristics of people who are at greatest risk of COVID-19 hospitalisation and death, and to develop risk scoring systems.2–5 These studies have been used to guide policy for public health interventions, for example, lockdown measures, patient shielding and prioritisation for vaccination.6 The QCovid algorithm is one such risk scoring system that predicts the probability of COVID-19 hospitalisation and death. It was commissioned by the chief medical officer for England on behalf of the UK government. Version 1 of the algorithm was trained using data from 1205 general practices (n=10.5 million patients) in England using data drawn from the QResearch database for the period 24 January 2020 to 30 April 2020.2 This period covers the 'first wave' of the pandemic in the UK, where testing and treatments for the disease were limited. Candidate predictor variables were selected on the basis of clinical plausibility, association with outcomes in other respiratory diseases and availability. A model selection process was followed that included removing variables with associated HRs close to 1, and variables whose predicted effect were clinically counterintuitive. The QCovid algorithm has been used by the UK government to inform policies on shielding and vaccine prioritisation for England.7
Following a request from the Scottish Government, we sought to externally validate the QCovid algorithm for the adult population resident in Scotland.
Approximately 99% of the residents of Scotland were registered with primary care facilities that provide a comprehensive array of healthcare services. During the acute phase of the pandemic, community based COVID-19 hubs (a general practitioner (GP)-led service designed to segment patients and reduce the risk of nosocomial infections) were established. We developed retrospective cohorts drawn from patients registered with any primary care practice in Scotland from the period 1 March 2020 to 24 October 2020.
We used data from all 940 Scottish primary care practices. Clinical data collected by primary care practitioners in Scotland have consistently been shown to be of high quality (90% completeness and accuracy8) and of great utility in epidemiological research.9–12 These were linked to the Electronic Communication of Surveillance in Scotland (national database for all virology testing including NHS (National Health Service) and UK Government test centre data), the Scottish Morbidity Record (record of hospitalisation data), and National Records Scotland (death certification) data as part of the Early Pandemic Evaluation and Enhanced Surveillance of COVID-19 (EAVE II) platform.3 A more detailed description of the data can be found in our cohort profile.13
Any individual in the relevant linked dataset between the ages of 19 and 100 was included. Individuals who had an outcome event (COVID-19 hospitalisation or death) in the first period (1 March 2020–30 April 2020) were excluded from any analysis in the second period (1 May 2020–30 June 2020) (figure 1).
Study design. GP, general practitioner.
Exposure variables were those used in the final selection of version 1 of the QCovid algorithm.2 These are detailed in box 1. All variables were taken as the most recent recorded value prior to the index date in the relevant dataset wherever available.
Predictor variables in the QCovid algorithm
Age in years (continuous).
Townsend deprivation score (continuous).
Accommodation (neither homeless nor care home, care home or nursing home).
Ethnicity in 10 categories (Bangladeshi, Black African, Black Caribbean, Chinese, Indian, Mixed, Pakistani, White British, White Other, Other, Unknown).
Body mass index (kg/m2).
Chronic kidney disease (CKD)—(no CKD, CKD3, CKD4, CKD5, unknown).
Learning disability (no learning disability, Down's syndrome, other learning disability).
Chemotherapy in last 12 months (none, chemotherapy group A, B, C, unknown).
Respiratory cancer.
Radiotherapy in last 6 months.
Solid organ transplant.
Prescribed immunosuppressant medication by general practitioner.
Prescribed leukotriene or long-acting beta blockers.
Prescribed regular prednisolone.
Sickle cell disease.
Chronic obstructive pulmonary disease.
Asthma.
Rare pulmonary diseases.
Pulmonary hypertension or pulmonary fibrosis.
Coronary heart disease.
Stroke.
Atrial fibrillation.
Congestive cardiac failure.
Venous thromboembolism.
Peripheral vascular disease.
Congenital heart disease.
Dementia.
Parkinson's disease.
Epilepsy.
Rare neurological conditions.
Cerebral palsy.
Severe mental illness (bipolar disorder, schizophrenia, severe depression).
Osteoporotic fracture.
Rheumatoid arthritis or systemic lupus erythematosus.
Cirrhosis of the liver.
The primary outcomes were time to COVID-19 hospitalisation (hospitalisation with reverse-transcription PCR (RT-PCR) positive COVID-19 test within 28 days prior to admission and up to 2 days after admission, or admission with ICD-10 codes for COVID-19) and time to COVID-19 death (all-cause certified death 28 days postpositive RT-PCR test from National Records Scotland).
Chemotherapy data were not available, so all individuals in the cohorts were assigned to the 'none' category for this variable. We also did not have data available indicating whether the individual had a bone marrow or stem cell transplant in the last 6 months, whether they had received radiotherapy in the last 6 months, and whether they had received a solid organ transplant. The values of these variables (chemocat, p_marrow6, p_radio6 and p_solidtransplant) were set to 'none' in the cohorts. For all other comorbidities/treatments, a missing value was taken to indicate absence of that comorbidity/treatment.
Ethnicity data were not available, and all individuals in both cohorts were assigned to 'white British'. The most fine-grained residential location information available in our dataset was data zone, which is a geographical designation comprising of groups of UK Census output areas. Output areas typically consist of ~300 people, whereas data zones typically consist of 500–1000 people.14 Townsend Deprivation Scores (TDS)15 for each output area were obtained from the 2011 UK census.16 We took the median value of TDS for the output areas comprising each data zone in order to get a deprivation score for each data zone. Missing values for TDS were replaced with the mean value for the cohort. Missing values in the housing category variable were taken to indicate the individual was neither homeless, nor resident in a care home.
We used ordinary least squares regression with all other independent variables included as predictors to impute missing values for body mass index (BMI). There is some evidence of an association between higher BMI and lower levels of socioeconomic status in developed countries.17 Sex is known to be associated with BMI, as is coronary artery disease and diabetes.18 19
There were no missing values for any of the other independent variables.
We applied version 1 of the QCovid algorithm to males and females in the validation dataset and computed Harrell's Concordance,20 the Brier scores, Royston's D,21 R2 21 and observed-expected ratio for the two time periods 1 March 2020 to 30 April 2020, and 1 May 2020 to 30 June 2020. Harrell's Concordance is a performance metric that characterises the tendency for people with higher risk scores to have earlier events. The Brier score is a measure of forecast accuracy that is equal to the mean squared prediction error. Royston's D is a measure of 'separation' between survival curves for individuals with different characteristics. R2 is a measure of the proportion of variation in survival time explained by the model. Observed-expected ratio is the number of observed events divided by the expected number of events predicted by the model. We made plots of observed vs expected risk by vigintiles of predicted risk. We recalibrated the algorithm in the second time period by scaling predicted risks by a multiplicative constant so that expected total number of events predicted was equal to observed total number of events.
This study is reported in accordance with the Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis guidelines.22
Characteristics of the study population
The total number of people in our dataset was 5 384 819, representing 99% of the entire population (5 463 300) estimated to be residing in Scotland in 2020.
After applying selection criteria, there were 4 392 014 individuals in the first time period cohort, and 4 382 281 individuals in the second time period cohort.
There were 5519 COVID-19 hospitalisations and 2693 COVID-19 deaths in the first time period. There were 5446 COVID-19 hospitalisations and 1300 COVID-19 deaths in the second time period. Hospitalisation and mortality tended to be positively associated with age and comorbidities (online supplemental tables 1 and 2).
[thoraxjnl-2021-217580supp001.pdf]
Table 1 shows Harrell's C, R2, Royston's D, Brier score and observed-expected ratio for the QCovid algorithm in predicting COVID-19 hospitalisations and deaths in our dataset for males and females in the first and second periods, respectively. Overall, the algorithm performed well according to these metrics. For predicting the risk of COVID-19 death in females in the first period, their values were: R2 0.72 (95% CI 0.71 to 0.73); Royston's D 3.28 (95% CI 3.20 to 3.37); Harrell's C 0.95 (95% CI 0.94 to 0.95); Brier score 0.0022 (95% CI 0.0008 to 0.0035); Observed-expected ratio 1.94. For predicting the risk of COVID-19 hospitalisation in females in the first time period, we found R2 0.47 (95% CI 0.46 to 0.49); Royston's D 1.93 (95% CI 1.87 to 2.00); Harrell's C 0.81 (95% CI 0.80 to 0.82); Brier score 0.0011 (95% CI 0.0009 to 0.0013); Observed-expected ratio 1.13. The performance metrics for males were mostly of a similar magnitude. The high values for Harrell's C, and low values for the mean squared prediction error (Brier score) are particularly notable. Figure 2 shows Harrell's C stratified by sex, period and age group. Concordance was relatively high, with 95% CIs tending to get smaller as age increased, likely due to the larger number of events. The calibration plots in figure 3 overall showed good agreement between observed and predicted risks, particularly in the first period, but with a tendency to overpredict hospitalisation and death for those at higher predicted risk in the second period, as reflected in the low observed-expected ratios (table 1). Figure 4 shows the results after recalibrating in the second time period. Agreement between observed and predicted risk improved markedly, though risk in the highest vigintile was underpredicted.
Harrell's C stratified by age, sex and period.
Observed and predicted risk.
Observed and predicted risk in second period, recalibrated.
Performance metrics for COVID-19 hospitalisation by sex and time period
This is the first national external validation of the QCovid algorithm for both COVID-19 hospitalisations and deaths. We found that the algorithm performed well against a range of performance metrics in males and females resident in Scotland for both the time periods under investigation. The algorithm showed good calibration in the first time period, and was improved in the second time period after recalibrating.
The QResearch database was used to train the QCovid algorithm.23 It links together primary and secondary healthcare records, RT-PCR testing results and mortality records. As of April 2020, 1205 general practices in England were contributing to the QResearch, with coverage of ~10.5 million patients. The QResearch database has been used extensively to develop risk prediction algorithms across the NHS (National Health Service).
Overall, the cohort used in the derivation of the QCovid algorithm and the validation cohorts used in this paper were statistically quite similar with respect to the marginal distributions of patient characteristics used in the algorithm. A notable exception is BMI; ~62% of the derivation cohort had BMI in the 18.5–30 range, whereas only ~32% of the validation cohort used in this paper had a BMI in the same range. There are also likely to be significant differences in ethnic background; 64.51% of the derivation cohort had 'white' ethnicity, whereas ~96% of the population of Scotland have 'white' ethnicity according to the 2011 Scottish census.14
Our study had a number of important strengths. We developed a unique linked dataset covering 99% of the population resident in Scotland. The EAVE II database3 is one of the few national individual patient-level linked research databases in the world.24 We evaluated the performance of the QCovid algorithm according to all metrics used in the original paper1 and for identical time periods to facilitate comparison of results. We used binned plots for the Brier score and observed-expected ratio as our chosen measures of calibration because we believe they are pragmatic and informative for policy-makers.
However, our work has several limitations. We did not have data available for chemotherapy treatment, bone marrow or stem cell transplants, and solid organ transplants. The values of these variables were set to 'none' for all individuals. We believe this was reasonable for evaluating the overall performance of the algorithm because these treatments were extremely rare in the original derivation cohort.2 These conditions are associated with slightly higher predicted risk of COVID-19 hospitalisation and death in the QCovid algorithm. Therefore, individuals with these conditions had slightly lower predicted risk than if this information was available. We also did not have access to ethnicity data, so all individuals were set to 'White British'. We believe modal substitution for ethnicity was reasonable because the most recent Scottish census indicated that 96% of the residents of Scotland identified their ethnicity as 'white'. We believe that minority ethnicities are more likely to have their ethnicity recorded by GPs in our dataset compared with white ethnicity and therefore missing values in the ethnicity field are likely to be disproportionately white compared with the population. Ceteris paribus, QCovid predicts slightly higher risk of hospitalisation and death for individuals of non-white ethnicity. Members of ethnic minority groups whose ethnicity was not recorded in our dataset will therefore have been assigned a slightly lower predicted risk of COVID-19 hospitalisation and death than if their ethnicity had been available. There was significant missingness in the BMI data, with 2 289 759 (52.1%) missing values in the 1 March 2020–30 April 2020 cohort, and 2 114 639 (48.3%) missing values in the 1 May 2020–30 June 2020 cohort. We used ordinary least squares regression to impute these missing values for BMI. We considered multiple imputation, but decided against it because it would not have been feasible given the high degree of missingness and the compute resources available to us. We believe that the average of multiple imputations would likely be similar to the mean predicted by OLS. We did not expect this to significantly affect the results of this validation exercise. The most fine-grained residential location information available in our dataset was data zone, which typically consists of multiple 2011 UK census output areas. We took the median value of the TDS for the output areas comprising each data zone in order to get a deprivation score for each data zone. Missing values of TDS were replaced with the average value for the cohort. Higher levels of deprivation as measured by TDS was associated with increased predicted risk of COVID-19 hospitalisation and death in the QCovid algorithm. The direction of the effect of having more finely grained residential location data available would have on QCovid predicted risk of COVID-19 hospitalisation and death is dependent on whether the TDS for an individual's output area is higher or lower than the median TDS in the output areas comprising their data zone. The algorithm had a tendency to overpredict risk of hospitalisation and death for those at higher predicted risk in the second time period. However, after recalibration there was good agreement between observed and predicted risk. This suggests that while QCovid risk scores showed good levels of discrimination of outcome, risk predictions from the QCovid algorithm may require recalibration in clinical practice.
QCovid has been used by the UK government to identify the clinically extremely vulnerable for shielding advice and to inform vaccine prioritisation policies in determining priority groups, in particular for those in Joint Committee on Vaccination and Immunisation category 6.6 Other potential applications of the algorithm include deciding who should be prioritised for treatments or boosters. QCovid is a 'living' risk prediction algorithm, in the sense that it can be trained on new data as these become available, and should show responsiveness to changing circumstances. The time period we studied corresponds to the 'first wave' of the pandemic in the UK during which treatments were limited. Availability and use of treatments have since improved. Since the period of study in this paper, several new SARS-Cov-2 variants have emerged, vaccines have seen widespread roll out in the UK, and policies on non-pharmaceutical interventions have evolved over time. Versions 2 and 3 of the algorithm are currently under development. Vaccination status and evidence of prior infection are planned to be used as predictors in version 3. The findings from this validation work have been communicated to the Scottish government.
Ethical permission for this study was granted from South East Scotland Research Ethics Committee 02 (12/SS/0201). The Public Benefit and Privacy Panel Committee of Public Health Scotland, approved the linkage and analysis of the deidentified datasets for this project (1920-0279).
The authors would like to thank staff at Public Health Scotland, Albasoft Ltd, the general practices that contributed data to the study and the EAVE II Collaborators. AS, JM and CR serve on The Scottish Government's COVID-19 Chief Medical Officer's Advisory Group and the New and Emerging Respiratory Virus Threats Advisory Group (NERVTAG) Risk Stratification Subgroup.
. Coronavirus disease (Covid-19) outbreak. Available: https://www.who.int/emergencies/diseases/novel-coronavirus-2019
Clift AK,
Coupland CAC,
Keogh RH, et al
. Living risk prediction algorithm (QCOVID) for risk of hospital admission and mortality from coronavirus 19 in adults: national derivation and validation cohort study. BMJ 2020;371:m3731. doi:10.1136/bmj.m3731pmid:http://www.ncbi.nlm.nih.gov/pubmed/33082154
Simpson CR,
Robertson C,
Vasileiou E, et al
. Early pandemic evaluation and enhanced surveillance of COVID-19 (EAVE II): protocol for an observational study using linked Scottish national data. BMJ Open 2020;10:e039097. doi:10.1136/bmjopen-2020-039097pmid:http://www.ncbi.nlm.nih.gov/pubmed/32565483
. Coronavirus (Covid-19): modelling the epidemic (issue no. 23), 2020. Available: https://www.gov.scot/publications/coronavirus-Covid-19-modelling-epidemic-issue-no-23/ [Accessed 18 Dec 2020].
Knight SR,
Ho A,
Pius R, et al
. Risk stratification of patients admitted to hospital with covid-19 using the ISARIC WHO clinical characterisation protocol: development and validation of the 4C mortality score. BMJ 2020;370:m3339.doi:10.1136/bmj.m3339pmid:http://www.ncbi.nlm.nih.gov/pubmed/32907855
GOV.UK: Joint Committe on vaccination and immunisation: advice on priority groups for COVID-19 vaccination, 2020. Available: https://www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-30-december-2020/joint-committee-on-vaccination-and-immunisation-advice-on-priority-groups-for-covid-19-vaccination-30-december-2020
. New technology to help identify those at high risk from COVID-19, 2021. Available: https://www.gov.uk/government/news/new-technology-to-help-identify-those-at-high-risk-from-Covid-19
Whitelaw FG,
Nevin SL,
Milne RM, et al
. Completeness and accuracy of morbidity and repeat prescribing records held on general practice computers in Scotland. Br J Gen Pract 1996;46:181–6.pmid:http://www.ncbi.nlm.nih.gov/pubmed/8731627
Sullivan FM,
Swan IRC,
Donnan PT, et al
. Early treatment with prednisolone or acyclovir in Bell's palsy. N Engl J Med 2007;357:1598–607.doi:10.1056/NEJMoa072006pmid:http://www.ncbi.nlm.nih.gov/pubmed/17942873
Dreischulte T,
Donnan P,
Grant A, et al
. Safer prescribing — a trial of education, informatics, and financial incentives. N Engl J Med 2016;374:1053–64.doi:10.1056/NEJMsa1508955pmid:http://www.ncbi.nlm.nih.gov/pubmed/26981935
SCOT-HEART Investigators,
Newby DE,
Adamson PD, et al
. Coronary CT angiography and 5-year risk of myocardial infarction. N Engl J Med 2018;379:924–33.doi:10.1056/NEJMoa1805971pmid:http://www.ncbi.nlm.nih.gov/pubmed/30145934
Ford I,
Murray H,
Packard CJ, et al
. Long-term follow-up of the West of Scotland coronary prevention study. N Engl J Med 2007;357:1477–86.doi:10.1056/NEJMoa065994pmid:http://www.ncbi.nlm.nih.gov/pubmed/17928595
Mulholland RH,
Vasileiou E,
Simpson CR, et al
. Cohort profile: early pandemic evaluation and enhanced surveillance of COVID-19 (EAVE II) database. Int J Epidemiol 2021;50:dyab028. doi:10.1093/ije/dyab028pmid:http://www.ncbi.nlm.nih.gov/pubmed/34089614
Scotland's census. Available: https://www.scotlandscensus.gov.uk/
Townsend P,
Phillimore P,
Beattie A
. Health and deprivation: inequality and the North. London: Routledge, 1988.
2011 UK census Townsend deprivation scores. Available: https://www.statistics.digitalresources.jisc.ac.uk/dataset/2011-uk-townsend-deprivation-scores
McLaren L
. Socioeconomic status and obesity, epidemiologic reviews. 29, 2007: 29–48.
Romero-Corral A,
Montori VM,
Somers VK, et al
. Association of bodyweight with total mortality and with cardiovascular events in coronary artery disease: a systematic review of cohort studies. Lancet 2006;368:666–78.doi:10.1016/S0140-6736(06)69251-9pmid:http://www.ncbi.nlm.nih.gov/pubmed/16920472
Bays HE,
Chapman RH,
Grandy S, et al
. The relationship of body mass index to diabetes mellitus, hypertension and dyslipidaemia: comparison of data from two national surveys. Int J Clin Pract 2007;61:737–47.doi:10.1111/j.1742-1241.2007.01336.xpmid:http://www.ncbi.nlm.nih.gov/pubmed/17493087
Harrell FE,
Califf RM,
Pryor DB, et al
. Evaluating the yield of medical tests. JAMA 1982;247:2543–6.doi:10.1001/jama.1982.03320430047030pmid:http://www.ncbi.nlm.nih.gov/pubmed/7069920
Royston P,
Sauerbrei W
. A new measure of prognostic separation in survival data. Stat Med 2004;23:723–48.doi:10.1002/sim.1621pmid:http://www.ncbi.nlm.nih.gov/pubmed/14981672
Collins GS,
Reitsma JB,
Altman DG, et al
. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. BMJ 2015;350:g7594. doi:10.1136/bmj.g7594pmid:http://www.ncbi.nlm.nih.gov/pubmed/25569120
QResearch
. Available: https://www.qresearch.org
Beever D,
Challen K, et al
. The UK's pandemic influenza research portfolio: a model for future research on emerging infections. Lancet Infect Dis 2019;19:e295–300.doi:10.1016/S1473-3099(18)30786-2
Twitter @DrAzizSheikh
Contributors AS and JH-C conceptualised the study. CR carried out the formal analysis. CRS wrote the initial draft of the manuscript. SK and EM assisted with the statistical analysis. SK wrote later versions of the manuscript. All authors assisted with review and editing. CR, EM and EV have verified the underlying data. CR is the guarantor for this work.
Funding Medical Research Council (MR/R008345/1), National Institute for Health Research Health Technology Assessment Programme, funded through the UK Research and Innovation Industrial Strategy Challenge Fund Health Data Research UK.
Competing interests JH-C reports grants from MRC, grants from Wellcome Trust, grants from NIHR, during the conduct of the study; other from ClinRisk, outside the submitted work. AS reports grants from NIHR, grants from MRC, grants from HDR UK, during the conduct of the study.
QCOVID in Scotland: time to recalibrate our expectations?
Rishi K Gupta Maarten van Smeden
Thorax 2021; - Published Online First: 15 Nov 2021. doi: 10.1136/thoraxjnl-2021-218169


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Centene Corp (CNC.N)
Managed Healthcare
CNC.N on New York Stock Exchange
Centene, WellCare win shareholder support for $15.27 billion deal
Shareholders of Centene Corp and WellCare Health Plans Inc voted in favor of a merger of the health insurers, setting the stage for the creation of a major new player in government-sponsored healthcare plans.
UPDATE 2-Centene, WellCare win shareholder support for $15.27 bln deal
June 24 Shareholders of Centene Corp and WellCare Health Plans Inc voted in favor of a merger of the health insurers, setting the stage for the creation of a major new player in government-sponsored healthcare plans.
June 24 Shareholders of Centene Corp and WellCare Health Plans Inc voted in favor of a merger of the two health insurers, setting the stage for the creation of a major new player in government-sponsored healthcare plans.
U.S. proxy firm ISS backs Centene's deal for WellCare
Institutional Shareholder Services has shown support for Centene Corporation's planned acquisition of smaller rival WellCare Health Plans Inc by recommending shareholders favor the deal, the health insurers said on Wednesday.
UPDATE 2-U.S. proxy firm ISS backs Centene's deal for WellCare
June 12 Institutional Shareholder Services has shown support for Centene Corporation's planned acquisition of smaller rival WellCare Health Plans Inc by recommending shareholders favor the deal, the health insurers said on Wednesday.
Proxy firm ISS backs Centene's deal for WellCare
June 12 Institutional Shareholder Services has recommended stockholders to vote in favor of Centene Corporation's planned acquisition of smaller rival WellCare Health Plans Inc, the health insurers said on Wednesday.
Humana says will not bid for Centene Corp
Humana Inc said on Monday it would not bid for Centene Corp, quelling speculation that it would acquire the health insurer that has already agreed to buy smaller rival WellCare Health Plans Inc for $15.27 billion.
UPDATE 2-Humana says will not bid for Centene Corp
June 3 Humana Inc said on Monday it would not bid for Centene Corp, quelling speculation that it would acquire the health insurer that has already agreed to buy smaller rival WellCare Health Plans Inc for $15.27 billion.
June 3 Humana Inc said https://www.sec.gov/Archives/edgar/data/49071/000119312519163308/d754845d8k.htm on Monday it would not make a proposal to combine with Centene Corp, which in March agreed to buy WellCare Health Plans Inc for $15.27 billion. In a statement, Humana confirmed it would not bid for Centene, adding it had chosen to comment "in light of the significant investor speculation and persistent market rumors".

redpajama_set_name: RedPajamaCommonCrawl


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Switzerland striker Frei ruled out of European Championship with knee injury
By BRADLEY S. KLAPPER, Associated Press
Switzerland striker Alexander Frei was ruled out of the European Championship on Sunday with a ruptured knee ligament.
The team's captain and record scorer was injured Saturday in the opening match of the tournament after he was fouled from behind. He left the field in tears and, after heading to the dressing room, returned to the bench on crutches.
Team doctor Cuno Wetzel said Frei would be out for about six weeks.
"Alex Frei knew immediately that he had been hurt badly," Wetzel said.
Switzerland coach Koebi Kuhn said it was a big loss, but added that the team would have to focus on coming back from its 1-0 loss to the Czech Republic.
"He was an important player. He was a goal-getter," Kuhn said. "But he's out. We have to move forward."
Frei was down for several minutes after being fouled from behind by Czech Republic defender Zdenek Grygera shortly before halftime. He slowly walked off the field, a trainer on each side holding him, tears streaming down his face. After going to the bench, Frei walked half the length of the field, again with a trainer at each side, and made his way to the tunnel. He was replaced by Hakan Yakin when the second half began, but returned on crutches to watch.
Frei went directly form the match to have tests done on his knee.
Wetzel said Frei would speak publicly Monday, but now wanted "to have some time to himself."
A forward with Borussia Dortmund, Frei missed much of the Bundesliga season because of injuries. He has had a hip operation, two muscle tears and a calf injury in the last 13 months, but had battled back in recent weeks to full fitness.
He became Switzerland's leading scorer on May 30 when he had two goals against Liechtenstein, passing Kubilay Turkyilmaz. He now has 35 goals in 60 international appearances.


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Chips Isn't Your Old Favorite #movie_Review
Juvenile humor, gratuitous nudity and a beheading…. I'm giving Chips a C.
A FBI Agent goes undercover in the California Highway Patrol as a motorcycle cop with a newbie partner. Dirty cops are holding up armored cars and it's up to Francis 'Ponch' Poncherello and Jon Baker as well as the rest of the highway patrol to stop the bad guys.
Based loosely on the late 70's TV show and written, directed and starring Dax Shephard as Jon Baker, this movie only uses the names and location from the original series. Although, there is a cameo of Erik Estrada. Jon Baker is a former X-Games star who must pop pain meds in order to get through a day after over twenty surgeries. He is sworn in as a patrol officer even though he didn't really pass the assessments and his motivation for becoming a cop is to win his wife back.
Michael Peña plays Ponch, a risky agent who has a sex addiction. He doesn't follow the rules and has been known to shoot his partners in order to get the bad guys. The undercover duty is his last chance to show his boss that he can "do it right".
Filled with slapstick humor and potty jokes, Chips appeals to a younger audience. Many of the old fan base including Erik Estrada complained that this new version made a mockery of the original show. The police in the movie are obviously incompetent such as when Ponch who is undercover begins interviewing other police officers and the widow of the fallen officer, when he's only a recent transfer. There were so many of those blatant inconsistencies to the way real police officers do their jobs.
If you go into dispelling reality and just enjoy the jokes, this movie will entertain. However, I would wait to catch it on rental or on Demand. Save the money.
Entertaining New Audiences- Beauty and the Beast #Movie_Review
Be Disney's Guest and enjoy the spectacular cinematography of Beauty and the Beast- I'm giving it an A.
A live-action retelling of the classic Disney fairy-tale about a girl with brains who takes her father's place as a prisoner in a cursed castle. Belle (played by Emma Watson) and her father (played by Kevin Kline) have moved to a small town in France. Belle's education makes her an outcast among the "provincial" town and she longs to learn more about her mother's death and the family's flight from Paris.
When her father gets lost in the woods on a sales trip, he finds a cursed castle and picks a rose for his daughter, sending him to the dungeon. The castle has been forgotten by the town around and hidden from sight for many years because the prince only looked for wealth and physical beauty instead of the real value inside. He was turned into a beast while his staff became a part of the castle. Belle trades places with her father and charms the beast. In turn, he learns the importance of looking deeper. After all, good-looking men like Gaston, often hide a cruel heart.
The Disney remake retains much of the original cartoon's songs and storyline but adds some depth to the characters. We learn about both Belle and Beast's families, and what made them who they are. The townspeople and castle servants are intertwined in a unique way and we see how the loss of love has affected them all.
Josh Gad as LeFou steals the scenes as Gaston's right hand man. He idolizes him, cares for him, and keeps him on the right track. But it's his own awakening to what is "morally correct" that changes things for everyone. Luke Evan's plays Gaston as a man on a mission, albeit one who has suffered as well. If only he'd have had someone to change him from a monster.
The CGI graphics of the beast are awkward at first but when you let the movie pull you in, they seem to fit. New songs and beautiful landscapes are sure to make this a movie you will want to see again and again.
Kong~ Monster or Friend? #Movie_Review
I went to see Tom Hiddleston but the giant ape steals the show… I give Kong: Skull Island an A.
The war in Vietnam is ending as the Cold War is heating up. A hidden island is found by a group of scientists with a hidden agenda. Convincing the military to support their expedition, they also enlist a former British agent and war photographer to go along. But the mission is doomed when they find giant monsters on the island.
John Goodman is the head of Monarch, a research company but he's hiding a secret and willing to do anything to find the answers and prove he was right. Samuel L. Jackson plays the head of the military unit. He's not ready to go back to civilian life and holds Kong responsible for the death of his men. The mission breaks something inside him. Tom Hiddleston's role as the former MI Agent is a departure from his previous roles. There's no snarky comments like with Loki and none of the smoldering sexiness of The Night Manager. He's all-military.
John C. Reilly is a wonderful surprise as a World War II pilot who crashed on Skull Island during the war and has found a home among the indigenous people. Being alone among people who hardly speak, he's a few marbles short and says exactly what he thinks. Each scene with him is a delight.
Filled with action and some amazing giant animals, Kong commands the screen. With a nod to the original Kong movie as Kong saves the girl after connecting with her. The expressive face portrays him as more human than ape. As a total reboot of the franchise, the after credit, sneak peek shows how Kong fits into Godzilla and hints at future movies in this series. Of course, having Tom speak out in the dark got me grinning. As a fan of the old Japanese Godzilla movies, the future hint speaks to some of my favorite creatures.
With non-stop action and amazing special effects, Kong kept me on the edge of my seat. It's a movie, I would watch again, just to catch all the nuances I missed. And then there's Tom Hiddleston… can't go wrong there.
Fitting End for a Super Hero #Logan #Movie_Review
Not your typical superhero movie, Logan pulls at the heartstrings. I'm giving it an A-.
Set in the future, Logan (played by Hugh Jackman) is slowly being poisoned by the metal skeleton as his healing properties are failing. Plagued by chronic pain, Logan works as a chauffeur in order to earn money to purchase medication for Professor X who he is caring for in Mexico. When a woman asks Logan to drive her and her "daughter" to North Dakota, Logan becomes the target of a deranged doctor who wants to create the perfect killing machine.
Laura (X-23) was created using Logan's DNA in a lab, along with other children. When the children are unable to become the killers they were bred to become, they are killed. Gabrielle, a nurse, along with others, sets out to save the children and enlists Logan's help. Unable to walk away from the money and with the Reavers on his tail, Logan, Professor X, and Laura set out on an epic road trip to stay alive.
Logan is a dark and violent movie. With the R rating, the violence jumps on the screen both from Hugh Jackman's character and Laura. Her moves mimic a ballet as she jumps, spins and tumbles through her action sequences. It's a little off-putting to see such a young child, so violent. Dafne Keen is amazing in her first movie role. Her expressive gaze shows way too much of her soul.
Patrick Stewart reprises his role as Professor X, now an old man with a brain disorder. Only medication keeps him from having a seizure and killing others. Patrick does an outstanding job as the broken former leader of the X-Men, now coming to grips with his own mortality. His mind is still a powerful weapon but like many elderly, his focus drifts between the past and the present.
Hugh Jackman's Logan harkens back to the earlier "I don't care" Wolverine, a badass with an attitude. His body is failing and his world has changed. His relationship with Professor X is touching. He cares for him and yet resents him at the same time. It feels like a parent/child relationship where now the child is caring for the parent. Some of the best moments come from the two men's interactions.
While the movie was outstanding, it had some inconsistencies which left you sort of lost. We know that the mutants are gone, but it's never addressed as to how and why. It also alludes to something that Charles did one year ago which he is blocking from his memory, but is never really explained. It's also poignantly sad that when the characters finally get a glimpse of happiness, the rug is pulled out from under them, leaving them angry and lost again.
Logan will be remembered as a turning point in the X-Men franchise and a wonderful send off for Hugh Jackman and Patrick Stewart who both have said that they won't be portraying these characters again. It also sets up a new series with new mutants. Just remember this isn't a happy movie and the R-rating is there for a reason. Don't bring young children to it.


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What Is a Nontariff Barrier?
Written By: Terry Masters
Edited By: Shereen Skola
A nontariff barrier is any policy or procedure that restricts imports but is not a tariff. Tariffs are government taxes on imports and exports that are used to control the balance of trade between one country and another. There are a wide range of national policies and procedures that can have the effect of restricting imports, ranging from national quality standards to unreasonable customs procedures. Generally, nontariff barriers can be grouped into three categories: barriers that directly aim to limit imports to protect a national interest, barriers that are regulatory and have the effect of limiting imports, and indirect barriers.
International trade organizations seek to promote global free trade, or open access to markets without restrictions. From a free trade perspective, a company in China should have unfettered access to the US market and vice versa. Demand for products should be the ultimate equalizer, and people should be able to make purchasing decisions based on their own needs and not a national government agenda.
Although free trade seems to be the ultimate expression of market capitalism, in reality countries want to protect their own industries, keep their workers employed and grow their economies. A country's economy depends on the balance of trade between it and other countries. In other words, governments strive to export more than it needs to import, or at least achieve an equal balance. If outside imports exceed exports, it can decimate a national industry and negatively impact economic production. A greater number of imports means that fewer works were employed to make goods at home.
To control imports, governments have traditionally imposed tariffs. Taxing imports makes it more expensive for other countries to access the national market. Imposing a tariff is a very direct way of trying to limit imports and is out of favor with international trade organizations. A nontariff barrier, however, can achieve the same result as a tariff without the government setting a specific import policy.
There are generally three categories of nontariff barriers. The first category directly aims to limit imports to protect an important national interest, such as the preservation of a particular industry or the promotion of a public interest such as lowering unemployment. An example of a nontariff barrier is an export subsidy or a customs surcharge on imports.
The second category includes barriers that are regulatory and have the effect of limiting imports. These barriers apply to national and foreign companies equally, but it tends to be harder for the foreign company to meet these standards because of the state of its industry. An example of a nontariff barrier of this type is a safety regulation for children's toys that is standard in one country but hard to implement by the importer.
Finally, indirect nontariff barriers are a third category. It includes any measure that is not intended as a trade restriction but has that effect. Examples include local laws and customs and traditions that have the unintended effect of discouraging the purchase of foreign products.
What Are the Barriers to International Trade?
What Is the Connection between Customs and International Trade?
How Do I Become a Customs Officer?
What is Customs Law?
What are Trade Sanctions?
What are Tariff Barriers?
What are Custom Ear Plugs?


To know accurately what a CRM system is? You can visit here to learn the basic definition. Building a good system is not very hard, but many people still repeat some common mistakes of CRM for an e-commerce website.
So what are mistakes that you should avoid?
A customer relationship management (CRM) program can combine and analyze information of customer such as name, age, nationality, purchased goods, number of successful purchases, etc.
Based on these data, it can list which items have good reviews and the highest revenue.
Some people don't want to spend money on software, so they use other free versions that lack some features.
These extra functions can help you a lot in keeping relation with your customers and make more money than you think.
It's not good if you force users to sign up for a new account when buying an item. Some customers are lazy to register and need to do it as quickly as possible.
Creating unnecessary process means making more obstacles for your customers.
You should insert a link from your website to customer's Facebook or Gmail account to make the clients feel more convenient and take more information from them.
When a new customer comes to your website, they may get confused and don't know what to do or how to buy a product.
If you have live chat support or a hotline on your site, clients can ask you at any time, and you can provide help for them immediately.
When customers understand related information clearly, they will feel informed and want to visit and purchase more on your website.
Creating a website is simple nowadays, but having a useful website that can show the professionalism is another matter.
The interface is one of the key factors for users to choose your website. The information should be well-organized and try to avoid complicated layout.
Remember that no one wants to have a difficult shopping time.
Please use moderate but helpful effects for the shoppers to access the products, purchase and pay as quickly as possible.
You should make a forum on your site, which is where people with similar interests can discuss and share information.
A forum will help new members become closer with your website and see it as a home, a familiar place.
Customer will frequent visits as well as introduce many other people to visit your website.
From the above advice, we hope you will never fall into any common mistakes of CRM for an e-commerce website.
E-commerce is a potential industry that hasn't been exploited fully, and if you want to start an Ecommerce website, we wish you success.
If you find this article helpful, please share it with your friends and colleagues.


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Trump says he has 'solution' to abortion debate
By Avery Anapol - 11/07/18 12:58 PM EST
President Trump Donald TrumpFacebook temporarily bans ads for weapons accessories following Capitol riots Sasse, in fiery op-ed, says QAnon is destroying GOP Section 230 worked after the insurrection, but not before: How to regulate social media MORE on Wednesday said he has a "solution" to the abortion rights debate, but did not provide details.
At a wide-ranging and sometimes confrontational press conference following the midterm elections, Trump was asked how he would "push forward" with his anti-abortion agenda, as promised during the campaign.
"I won't be able to explain that to you," Trump said. "Because it is an issue that is a very divisive, polarizing issue. But there is a solution, I think that I have that solution. And nobody else does."
Trump on his "pro-life agenda": "What will I do? I will not be able to explain that to you. Because it is an issue that is a very divisive, polarizing issue. But there is a solution, I think that I have that solution. And nobody else does." pic.twitter.com/0hVlvcvnrG
— Aaron Rupar (@atrupar) November 7, 2018
The debate over abortion rights is seeing renewed energy following the confirmation of Trump's latest nominee to the Supreme Court, Brett Kavanaugh Brett Michael KavanaughWhy we need Section 230 more than ever 'Almost Heaven, West Virginia' — Joe Manchin and a 50-50 Senate Murkowski says she is not considering joining Democratic caucus MORE.
Kavanaugh, a conservative justice, is seen as a potential tie-breaker to overturn the landmark Roe v. Wade ruling, which legalized abortion in the U.S., should the opportunity arise.
The president offered other vague information about his next moves following the midterms, including potential Cabinet shake-ups and his response to Democrats possibly seeking his tax returns.
Tags Brett Kavanaugh Donald Trump


Those who choose to pursue careers in patient care almost always find the rewards to be more than gratifying, yet the associated challenges to be more than they ever anticipated. In order for you to be able to deliver the high-level of care that your patients both need and deserve, you need to have a good number of resources at your disposal. Not to worry, we here at Eighth Street Capital are happy to provide you with them.
Don't allow the financial challenges that come from running your own patient care clinic deter you from providing everything the perpetual well-being of your patients requires. Let us here at Eighth Street Capital help you by offering the funds needed to meet the many financial demands of your practice. To learn more about the details of our healthcare and medical financing programs, just give us a call today.


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America Prepares to Surrender to the Taliban
After months of negotiations, the U.S. seems prepared to come to an agreement with the Taliban, according to which Washington will remove its troops from Afghanistan while the Taliban will agree to share power with the country's current government and provide assurances that it will cease allying with terrorist groups and instead become a partner in combating jihadists. Andrew C. McCarthy comments:
The Taliban will soon be ruling Afghanistan again, just as it did in those years before 9/11. That is when al-Qaeda was encouraged to make Afghanistan the headquarters of its global anti-American jihad. In recent years, while we were fixated on Islamic State, al-Qaeda became stronger, more resilient, and more battle-hardened. When the Taliban retakes control, al-Qaeda will be right back in business. Lest we forget, its business is killing Americans.
American forces have been deployed in Afghanistan for eighteen years. It may seem like an endless mission because of the half-hearted, ill-conceived way it has been executed. But is it an "endless war"—to borrow President Trump's worst hyperbole (which is saying something)? If it is, that is only because our enemies have never stopped being at war with us, and we have never resolved to defeat them. . . .
Al-Qaeda remains closely aligned with both Taliban leadership and the most important Taliban elements—such as the [Pakistani terrorist groups] Haqqani network and Lashkar-e-Taiba. At the same time, unsurprisingly, the Taliban continues to terrorize, and to deny the legitimacy of, the rickety, U.S.-backed government in Kabul—whose days are numbered once U.S. forces exit.
Bluntly, by pulling out of Afghanistan at this moment, we are enabling re-creation of the conditions that obtained circa 1998 through 2001. That is when al-Qaeda repeatedly mass-murdered Americans, attacking our embassies in eastern Africa, our naval destroyer Cole, and, ultimately, the World Trade Center and the Pentagon.
[The truth is], it is easy to end an endless war. . . . All you have to do is surrender.
Read more at National Review
More about: Afghanistan, Al Qaeda, Donald Trump, Taliban, U.S. Foreign policy, War on Terror
Why It's Necessary to Bring Jewish Communism into Full View
How to Judge Robert Alter's Landmark Translation of the Hebrew Bible
Hillel Halkin
Distrust of the Supreme Court Led Likud Voters to Rally around Netanyahu
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A few weeks ago, Benjamin Netanyahu handily won the Likud party's primary election, receiving 72 percent of the votes. He won despite the fact that he is facing indictments on corruption charges that could interfere with his ability to govern if he remains Israel's premier, and despite the credible challenge mounted by his opponent, Gideon Sa'ar. Evelyn Gordon credits the results not to love of Netanyahu but to resentment of Israel's overweening Supreme Court:
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Read more at Evelyn Gordon
More about: Benjamin Netanyahu, Israeli politics, Israeli Supreme Court
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Smiths Group has opened talks with US companies over a potential £6bn deal to merge its healthcare operations.
The engineering giant is said to have held early-stage discussions about combining its healthcare arm with a string of companies, including California's ICU Medical.
The move has been spearheaded by chief executive Andy Reynolds Smith and has been spurred by speculation that it has become an activist investor target. Smiths, which makes devices from airport security scanners and medical equipment to electrical connectors and hoses, has seen its share price endure a choppy ride in recent months.


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Q: Wordpress: Reescrever linha de código Preciso reescrever uma linha de um Plugin no Wordpress utilizando o functions.php, tentei utilizar o add_filter porem não funciona.
Basicamente eu preciso fazer assim, este é um exemplo da linha original:
$return = $post->post_title;

Porem, eu preciso através do functions.php deixar ela assim:
$return = strtoupper($post->post_title);

Existe alguma possibilidade para isso?

A: seu plugin precisaria estar com um filter no codigo
$return = apply_filters('my_plugin_post_title', $post->post_title);

e você aplicaria no seu functions.php isto:
function uppercase_title( $title ) {
    return strtoupper($title);
}

add_filter( 'my_plugin_post_title', 'uppercase_title');

redpajama_set_name: RedPajamaStackExchange


The Money Farmers 2012 – BBC Panorama | Gerald Celente Trends Blog.
The Secrets of The Dark Night Rises Leaked | Gerald Celente Trends Blog.
Texe Marrs – Sayanims Everywhere | Gerald Celente Trends Blog.
this is freakin awesome!! – One Vibration.
The Tablets Of Destiny Alchemy & The Philosophers Stone – by Joseph Farrell | Gerald Celente Trends Blog.
Greece – The Great Depression is Already Here | Gerald Celente Trends Blog.
The Neocon Agenda PNAC 9-11-01 | Gerald Celente Trends Blog.


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Home Retail Retailer of the Year: Twin Liquors
Retailer of the Year: Twin Liquors
Long known in the Austin, TX, area as an expansive chain of well-appointed beverage alcohol stores, Twin Liquors made a emphatic statement to potential competitors with the November 2008 opening of its Hancock Center Marketplace flagship location, in greater Austin'€™s Hyde Park district. The 15,000-square-foot, cutting-edge megastore, built in the shell of a former Old Navy outlet, has most everything a customer could want, blending a roomy, comfortable layout '€" accented by large granite tasting bars in center store and by the entrance as well as classroom-style enclaves in back – with an impressive selection of wine, beer and spirits. Continuing to highlight its chain-wide signature trademark '€œTwin Deals'€ promotion, which offers two bottles at a deep discount, along with a wide array of tasting and educational events, the new store drew enthusiastic reviews from customers on ratings sites like Yelp! One online poster noted the store is a '€œmassive celebration of wine, liquor, beer and more'€¦'€
Call it the latest evolution in a family-based enterprise that, starting with its roots in the aftermath of Prohibition, has shown an uncanny knack over the decades of anticipating beverage alcohol retailing trends while retaining a homey, family feel. On the trends front, Twin Liquors was early to key in on wine and food pairings, and among the first to work to make its stores more appealing to women with a focus on education and nicely finished stores. Oh, and it'€™s also developed a remarkable degree of regional goodwill with an extensive charitable giving program that encompasses the arts, medicine and education.
Now run by the third generation of Jabour family members since the company'€™s founding immediately after the repeal of Prohibition in 1933, Twin Liquors operates 59 stores, with its newest location, which opened in November, being a twin to the Twin Liquors Marketplace at Hancock. They all operate within a 65-mile radius of Austin under the store names Twin Liquors, Reuben'€™s Wine & Spirits, Dan'€™s, Hill Country Wine & Spirits and KP Liquor. The retailing mini-empire reaches into such towns as Round Rock, Pflugerville, Cedar Park, Georgetown, Dripping Springs, Marble Falls, San Marcos, Kingsland, Burnet, Lockhart and Taylor. At the helm, juggling a variety of roles, are David Jabour and his sister Margaret Jabour.
Twin Liquors Roots
The Jabour presence in Texas goes back more than a century, when the family of Lebanese immigrants set up a mercantile store in the late 1800s at the intersection of Congress Avenue and Pecan Street (later renamed Sixth Street), in the heart of the city. During the boom in liquor retailing that commenced upon Prohibition'€™s repeal, the family opened Jabour'€™s Package Store, vying with two dozen operators that sprang up within a two-mile area. By the mid-1940s, the next generation of Jabours had expanded to three liquor stores and a beer tavern. The current third-generation managers, David and Margaret, took over in 1981 when the second generation retired. The next year they'€™d adopted the Twin Liquors moniker with the opening of a 700-square-foot store at the corner of 7th and Red River in downtown Austin. This was in honor of their father, the twin, Theodore Jabour. The third generation consisted of David and Margaret Jabour alongside their dad, Theodore Jabour (deceased November 2009), Ralph Jabour (deceased January 1990) and Gabe Diab, an uncle on their mother'€™s side.
As Austin began to experience its long-running boom in the 1990s, with its technology companies drawing new residents from California and other areas with sophisticated tastes in alcoholic beverages even as the University of Texas grew by leaps and bounds, Twin Liquors commenced on its twin '€" if you'€™ll pardon the phrase '€" expansion track of new stores and acquisitions. The acquisitions included Dan'€™s Wine & Spirits in 2000, Reuben'€™s Wine & Spirits in 2001 and KP Liquors in 2003. All three family-run businesses, Twin Liquors maintains, sought it out as the preferred acquirer. With the opening of the Marketplace concept store at Hancock Center, Twin Liquors now boasts an extensive network of stores under numerous brands, sizes and retailing approaches. '€œTen years of major growth and now another plateau,'€ said Margaret with satisfaction.
Asked whether a statewide expansion in Texas or perhaps to neighboring Arizona is contemplated, David replied drily: '€œIt'€™s not in our one-year plan.'€ Added Margaret: '€œTexas is different. Not everyone can operate in this state.'€ She noted, though, that Twin Liquors'€™ focus around Austin puts it in a great position to expand elsewhere in the state, thanks to the awareness that is built among the legions who are drawn to Austin to attend classes at the University of Texas or to attend to business at the state capitol.
Tightly Knit Family Business
Though David and Margaret Jabour can recall being involved in the family business since they were 6 or 7, they both can boast significant business experience outside the world of Twin Liquors. David spent 15 years in commercial banking, though '€œthe family business was never out of arm'€™s reach,'€ he said. The firm financial grounding offered a springboard to take the business to new heights, he believes.
Margaret took somewhat less of a digression. '€œI was always going to do retailing,'€ she recalled. As early as her teens, she was involved in a stereo business selling car stereos and recorded music. Her junior year in high school she opened an electronics store, along with her Uncle Gabe. Another sibling, Ralph, was a biochemist who, even in the early 1980s, wanted to elevate the still-provincial wine tastes of Austin and was beating the drum for wine and food pairings. Suffering from health issues since childhood, Ralph Jabour died of heart disease as a young man, though his brother and sister say the continuing impact of his ideas on the business has been incalculable. '€œThere'€™s a glow,'€ they both added. As for their Uncle Gabe, '€œUncle has always been our out-of-the-box thinker who has inspired us to expand and compete,'€ they said.
Operating as a tightly knit family confers a unique style. Responsibilities are loosely defined, a good counter to any impetus to creeping bureaucracy. Generally speaking, as president, David manages operations while Margaret, as executive vice president, handles community, supplier and customer relations. The family is able to benefit from relationships with key distributors like Glazer'€™s and Republic that go back to their grandfather'€™s time, Margaret said. In the case of suppliers like Gallo, the families have been doing business together for 70 years, David noted. '€œIt'€™s important for executives to understand the family dynamic,'€ he said. As for the next generation, Margaret has sons age 18 and 16 while David has a pair of twins age 8 and a 6-year-old whom they hope will someday choose to be involved in the family business.
Respecting Tradition
That sense of abiding by family and tradition has also dictated a key aspect of Twin Liquors'€™ branding strategy: maintaining the identity of acquired chains, often for considerably long periods. Twin Liquors executives assert that one of the reasons the other owners approached them about a deal was the belief that they would be the best successor to maintain their business'€™s continuity and look out for their employees. Following an acquisition, '€œwe evaluate the merit of that brand,'€ said David. '€œThe last thing we want to do is remove the goodwill. In due time it becomes integrated with the Twin Liquors brand, but we don'€™t do so unnecessarily. That would be frivolous. It wouldn'€™t be respectful.'€
Though the stores retain their individual identities, tied both to their neighborhood and to their brand, they'€™re all marketed together, with all promotions and point-of-sale materials delineated as coming from Twin Liquors. It'€™s like they have different first names but the same last name, David figures.
Also critical to the Twin Liquors DNA is the blending of small-footprint neighborhood stores, running to 750 wine SKUs at the low end, with larger destination stores focused on education and customer interactions, all configured within a finite geographic area. The larger stores sport 7,000 SKUs '€" a large but manageable variety.
The company also plays off the '€œtwin'€ in its name whenever it can in its promotional activities, notably with its '€œTwin Deals'€ program featuring two of the same featured national brand at a hot price, and its store associates'€™ '€œTwin Picks.'€
Presenting Wines
In the stores, Old World wines generally are shelved in wood on the wall, while most domestic and New World wines are merchandised on the floor, organized by varietal. California wines do exceptionally well in Texas and receive great prominence at all Twin Liquors stores. French wines don'€™t fare so well, though David noted that consumers are getting further acclimated to wines from regions like the Southern Rhone, which go well with the types of cuisine that are popular in the state. And the quality of Texas wines continues to improve, he said.
Brenda Audino, chain-wide wine manager, said that, as elsewhere, Malbecs are doing really well. In general there'€™s an emphasis on value lines under $15, featuring varietals and producers that consumers are familiar with '€" '€œcomfort wines,'€ Audino calls them. At in-store tastings, where much of the risk of the unknown is eliminated, they'€™ll venture higher in price, she said.
At a time of austerity in many households, California and Washington State wines do well. Argentina is '€œhot as a firecracker,'€ David said. With prices usually running below $15, sometimes even below $10, Spanish wines also do well; these days, consumers are willing to experiment with a wide variety of entries, not just riojas, and the quality is definitely there, the Jabours said. Portuguese still wines are showing some vibrancy. And New Zealand sauvignon blanc is a winner.
The burgeoning Texas wine industry poses an interesting dilemma. On the one hand, Twin Liquors is eager to promote local producers. But it won'€™t do so at the cost of compromising the overall quality of its selections. '€œTexas is a very young and vibrant industry,'€ Audino puts it, diplomatically. '€œThey have to figure out what are the best practices for this particular hostile environment. They'€™re in every one of our sets. It takes a while to figure out what works but some are making great strides.'€ She cites Becker Vineyards, Alamosa Wine Cellars and Fall Creek among those who'€™re bringing out '€œfabulous'€ wines. Indeed, David Jabour rates Becker'€™s viognier among the best in the world. For his part, Becker winemaker Russell Smith, who spent more than 11 years as a Twin Liquors manager before returning to the winemaking side two years ago, said he has no complaints about the attention his and other Texas vintners have received at the chain. '€œWe'€™ve appreciated their help over the years, and their encouragement and enthusiasm for new wines. We consider them an important part of our success,'€ he said. During Texas Wine Month, in October, Twin Liquors integrated Texas wines '€œat any time possible,'€ Margaret Jabour said.
Individual stores are given a great degree of autonomy in keying their wine selections to their local customer base. '€œWe have more than 10,000 wines that the stores can choose from,'€ Audino said. '€œSo they can customize their wine selections to fit their demographics and interests. And if customers ask for something specific, we'€™ll bring it in for them.'€
The Spirits Side
On the spirits side, vodkas of every stripe are selling well '€" including an array of sweet-tea vodkas that play to a regional tradition. Bourbon has been hot, playing both to a back-to-basics sentiment and chauvinistic identity as our domestic spirit. Texas is a major tequila market, with current momentum behind value-priced 100% blue agave tequilas.
Twin Liquors is emphatically not playing the private-label game. Its executives maintain that they can be counted on to remain crucial allies of the national brands. '€œWe are totally focused on national labels, versus the temptation for private label,'€ said Margaret. '€œWe don'€™t want to see any of these labels diminished in any way.'€ Added Audino: '€œI don'€™t know how people can do it without the support of the supplier network. Nobody can be out there as an island.'€
Though the Jabours feel they offer a solid selection of domestic and imported beers '€" after all, with its hot weather and many Hispanic consumers, Texas is very much a beer state '€" '€œwe like to focus on liquor and wine,'€ said Margaret. '€œWe want to impact them with comfort in making that mixed drink,'€ particularly at a time that the recession is pushing people to do more entertaining at home. That said, the chain does well with craft beers, both regional ones and national ones like Dogfish Head, and retro brands like Lone Star, are showing vigor, especially since the economy softened. Texas icon Shiner Bock is a perennial favorite.
'€œMy take on Twin Liquors is they have a great selection,'€ said Austin-area resident James Hyde, an ad sales executive at BusinessWeek magazine, who developed a serious interest in wine when he earlier lived in San Francisco. '€œSome of their bottles are well-priced and they make their money on others.'€ He views Twin Liquors as the connoisseur'€™s ally. As a fan for special occasions of pricy vineyard-designated Chardonnays from Kistler Vineyards, Hyde marvels that at the Hancock Center store, '€œthey have a couple I'€™d never seen at a liquor store.'€ He terms that store '€œextraordinary.'€
Accent on Education
The central concept of the Marketplace store is on education '€" both of consumers and Twin Liquors'€™ staff '€" and the superstore is host to daily tastings at its 20-foot tasting bar, hostings of winemakers '€" including celebrity draws like Danny DeVito (sidebar) and the free Wine 101 classes. A fine wine room seats 12 and the education room can host white-tablecloth dinners for 40. All these activities are boosted by new state law that allows up to 20 items to be offered for free tastings.
The popular Wine 101 classes are held on the first and third Wednesday of every month. Taught by Audino or one of three other employees trained to manage it, they run about an hour and a half, taking students through the '€œbig six'€ grapes and their primary growing regions, and teaching attendees to be comfortable with what their likes and dislikes are. Consumers get to taste wines, receive a take-home packet and are allotted time to wander the store, with the instructor on hand to field their questions. Besides helping to build a consumer base and generating some immediate sales, the sessions comprise a form of market research that helps Audino to refine her own purchasing choices for the stores.
If Marketplace is high-concept, that by no means diminishes Twin Liquors'€™ other locations, Margaret Jabour said. In all of them, passion, personality and expertise are sought in store associates, whose ability to forge enduring relationships with their customers are regarded as a key to the company'€™s success over the decades. Though wine authorities like Robert Parker are viewed as providing useful information on wines worth a look, the burden in easing customers through their choices is placed on the associates, whose personal preferences are posted as Twin Picks. Loyalty cards for regular purchasers are eschewed as too impersonal.
Though the general rise in consumer awareness of wine, along with Texas'€™ own thriving winemaking scene, would seem already to have done the hard work of demystifying the segment, the Jabours are not taking that progress for granted. '€œJust as there'€™s a new freshman class at the University of Texas every year, there'€™s a new group of 21-year-olds as well'€ who need to be brought along in appreciating the joys of wine, Margaret Jabour noted. The store associates are on the front lines of that education process.
The ambition is that they convey '€œthe passion they have behind wine '€" the stuff they'€™re drinking at home,'€ Audino said. In hiring, Audino said, '€œwe'€™re looking for that passion, that spark behind the eyes, a willingness to learn. I can give them the knowledge'€ '€" say, through the 9-week wine authority course she teaches for the chain'€™s employees '€" '€œbut I can'€™t give them passion.'€ So far, close to 100 employees have gone through the rigorous course, which takes them through areas like viticulture, grapes, regions, sparkling and fortified wines, food pairings and sales techniques. Each class concludes with blind tastings. '€œWe try to taste wines that really should be in all of our stores and maybe are overlooked,'€ she said. The four-hour courses are held once a week; employees are paid for their time there. Those who pass the concluding exam receive a personal copy of the Hugh Johnson/Jancis Robinson World Atlas of Wine and a certificate that, while it doesn'€™t confer any immediate jump in status or compensation, is an important factor in considering employees for promotion.
To motivate associates, they are challenged in contests measured on sales of target products, in which they receive points for different brands they sell. Winners receive trips to wine-producing regions '€" Spain and France, in one such trip last year, and Napa in another. For 2010, the trips are to Italy, Sonoma/Napa and Oregon.
No discussion of Twin Liquors would be complete without a mention of the Jabour family'€™s charitable activities, supporting cause ranging from the Long Center, which manages three arts institutions, to the American Cancer Society'€™s Cattle Baron'€™s Ball, to hundreds of lower-key, more local events staffed by the local store team. Though for decades the Jabours were happy to make their donations quietly, their managers are grateful to see the chain getting greater local recognition for its contributions.
'€œI'€™d hear '€˜thank you'€™ a lot from customers, but never noted Twin publicly getting the recognition it deserves,'€ said Sandra Spalding, community events manager. She notes that her own background in art history and performance, along with past experience in the restaurant business (not to mention a stint running a Twin Liquors store during her decade-long association with the company) has equipped her well for her current role, which encompasses events, marketing and public relations.
The driving force is charitable events, usually annual events, in which Twin Liquors can play roles ranging from simply taking an order to helping with the logistical planning. Some are outright donations to worthy causes, while others offer cross-promotional opportunities that directly help build the business. '€œWe'€™re all over the wine and food festivals,'€ Spalding said. If children are involved in the charity, the company gives but asks to remain anonymous. The company gives to more than 400 organizations per year, and that broad scope '€œhas made my job so easy: it allows me to say yes to almost everything in some form,'€ Spalding said.
Serving as President of the ABL
In March, David Jabour stepped up to a two-year term as president of the American Beverage Licensees, which styles itself the voice of '€œAmerica'€™s beer, wine and spirits retailers.'€ Jabour previously had served as a member of the ABL board for seven years and served on its executive committee for five. His priorities?
'€œFirst and foremost is broader membership,'€ he replied. '€œWe'€™ve got more than 20,000 on- and off-premise retailers but we still need to broaden it.'€ That means convincing state associations that are not ABL members to join, or incubating an association where necessary. While the ABL boasts affiliates in major states like Texas, New York, Illinois and Massachusetts, there are some conspicuous voids, none more so than California. The Golden State'€™s domination by chains has tended to make it more difficult for family businesses like the ABL'€™s membership to get involved at that level (though some may still have a voice through the Wine & Spirits Guild of America, an affiliate of ABL).
At the national level, the federal excise tax clearly will be a major issue, Jabour said, and the ABL will work with the Distilled Spirits Council (DISCUS) and the Wine & Spirits Wholesalers Association (WSWA) to protect retailers'€™ interests. Nor is there any waffling by the ABL on another contentious issue, that of direct shipping. '€œThe ABL embraces the three-tier system: it works and is functional,'€ he said.
Another initiative is not surprising coming from a president who has parlayed his regional roots into such a strong business: a shift of the ABL'€™s annual convention from Las Vegas to Louisville, Ky., in June 2010, so the industry can bask in the history and traditions of Bourbon whisky. In a play on the familiar '€œWhisky Trail'€ that lures Bourbon aficionados, the convention theme is '€œOn the Trail to Success.'€
Theodore Jabour, 88
Tragically, moments before David and Margaret Jabour were to be photographed for this story, they received an emergency phone call from the hospital where their father Theodore was being cared for. Up until that day, David frequently interrupted his business routine to attend to his father'€™s needs, an '€œ88-year-old young man with heart issues and on dialysis,'€ David stated. In our original story, David noted, '€œHe'€™s always been a wonderful inspiration for us, and always enjoys being involved, knowing what new projects and strategies we have.'€ Added Margaret: '€œThere'€™s a glow in his eyes when we talk of new locations.'€
Theodore Jabour passed away on Monday, November 23, 2009. One obituary noted that '€œhe and his identical twin brother, Arthur, loved working in their family business'€¦.
Theodore'€™s business philosophy provided the foundation for Twin Liquors'€™ existence. He fundamentally instilled in his children the importance of trust, relationships, customer service, and how serving and helping one'€™s community is an essential component of fulfilling the needs of customers. This philosophy ultimately fueled Twin Liquors'€™ great growth.'€
And a different obituary described the twin brothers roaming '€œthe streets, parks and creeks of a much smaller Austin as boys. They fired anti-aircraft guns side by side in the Pacific theater in World War II, stood together in front of an Eastern Orthodox priest as they married in the early 1950s'€¦'€ and spent almost four decades together running Jabour'€™s Package Store until they retired in 1981. Fortunately, Theodore soon came out of retirement to help his children found Twin Liquors.
A testimony to Theodore on the Twin Liquors website sums up: '€œTheodore remained active in Twin Liquors until his death providing passion, wisdom and direction to the company. Even days before his death, the sparkle in his eyes and vigor in his voice when discussing company business confirmed his unwavering and steadfast commitment to his community, industry and family. In an era when businesses rise and fall with relatively brief periods of success, it is reassuring to find that Twin Liquors has stood the test of time because of the beliefs of its founder. That'€™s the real testimony to honoring a heritage, a family and a father.
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text:
Even After Tragedy the Show Must Go On
May 22, 2013 Ryan Anderson	Leave a comment
Events like the recent tornado in the suburbs of Oklahoma City show the insignificance of sports in the grand scheme of things.
Events like the recent tornado in the suburbs of Oklahoma City also show the significance of sports in the grand scheme of things when it come to returning to normal following a tragedy.
FEMA command centers like this one will soon be a sight all over Oklahoma.
While nothing can instantly make everything better for those who have lost loved ones, a lifetime of possessions, and are trying to rebuild their lives while wondering why the same area would get hit by devastating twisters roughly a decade apart, the presence of sports can have a soothing effect while also serving to bring resources to the recovery that may not have been there otherwise.
Today across the country college baseball teams will start their conference tournaments to determine who makes it to the College World Series.
In the Houston area that means the Southland Conference and Conference USA will be holding tournaments at Star Tex Field in Sugar Land and Reckling Park at Rice University respectively.
UCF and Rice University are set for a showdown with the Conference USA crown at stake.
Another tournament for the Big 12 was also slated to start today in Oklahoma City. The stadium hosting the tournament, which is also home to the Houston Astros Triple-A affiliate, is about 10 miles from the devastation area.
With such close proximity to the devastation tourney directors were faced with deciding whether to go on with the tournament, or to cancel it altogether. In the end they decided to delay the start of the tournament by a day to add time to recover.
In situations like this there will always be those who say the tournament should have been cancelled in light of the tragic events and to hold the tournament is being insensitive to the victims.
I do not share that opinion.
During an active event where resources were stretched to the point where holding the tournament would become a strain to the cities hosting them then of course I would say to cancel the tournament; but this is not the case.
Public officials from the governor down to the mayor have expressed a desire for the Big 12 Tournament to continue as planned so it is not like the Conference officials are proceeding without the blessing of the proper authorities.
Stories are already reaching the media of teams chipping in to help the victims of the storms. Were the tournament cancelled those teams would not still be there to help.
One such example is the University of West Virginia baseball team going to Walmart and buying items to distribute to the victims. There are likely many other gestures that are being done by teams that are not being publicized.
In addition to the efforts of the universities taking part in the tournament, it is likely that donations will be taken at the ballpark as well to help the victims. There is also a very strong likelihood that portions of the ticket sales will go towards the victims. While many people may want to donate, a collection box at the ballpark gives them an easy way to do that. It is the same way that the annual Salvation Army Red Kettle Campaign does so well.
UCF won the series during their last visit to Rice University in April. They will hope for similar results this weekend.
None of these things could happen if the tournament was cancelled so the value of the show going on becomes evident.
I believe that by and large people want to help out in times of trouble but many may not know how. By making it as easy as possible for them, they are able to contribute.
In the spirit of making it easy to contribute to the relief effort, people can make an automatic $10 donation to the Red Cross by texting REDCROSS to 90999 or the Salvation Army by texting STORM to 80888 . While by in no means are these the only organizations collecting they are certainly two places to start.
It will likely take years for the areas hit by the tornado to recover but as they have shown from the time of the Dust Bowl to today the people of the Midwest are a resilient people and ones that can recover from adversity stronger than before.
Stories of heroic actions by teachers shielding their students with their bodies as the storm tore through their school, to pets being reunited with their owners, show some of that never say die attitude and willingness to help others in their darkest moments. Sadly there were lives lost in the storm but early warning systems provided a critical 16 minutes to allow those that could to seek shelter. Few can argue that the 16 minute warning saved lives that would have been lost with less notice of the approaching tornado.
Personally I would rather face hurricanes than tornadoes. At least with hurricanes there are usually days if not weeks to prepare for the impact. Tornadoes do not offer that luxury and are a major reason why as much as I love the suburbs of Dallas, and even picked out a loft overlooking a ballpark that I thought would be fun to live in, I do not think I could ever live there due to it being part of Tornado Alley.
Hurricanes announce their arrival days in advance unlike tornadoes that strike in an instant.
I have definitely gone through my share of hurricanes and have seen first hand the devastation that they can cause but it is nothing compared to what a tornado can bring. I hope to never have to face a tornado head on but if I ever do I will know that sports will be there as a calming factor as I rebuild from the devastation.
So let the games go on as the recovery from the tornado takes place and know that the rebuilding will still be going on long after the stadium lights dim but the people of Oklahoma will recover as they have many times before. After all, it takes a certain kind of person to live in a zone where on any given day everything they know can be turned upside down in an instant.
And while they are adversaries in the annual Red River Shootout between the University of Texas Longhorns and the University of Oklahoma Sooners, there are definitely times to put football partisanship aside and just be one human being helping another. And this is one of those times.
Now if you'll excuse me I am off to get ready for the Conference USA Tournament at Rice University but first I have a donation to text.
college baseball tournamentsOklahoma CityRice Universitytornando recovery


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Supreme Court upholds double-jeopardy exception: What it means for Trump associates
On Behalf of Roberts Law Group, PLLC | July 3, 2019 | Criminal Defense
The double jeopardy clause is one of the foundations of our criminal justice system. The Fifth Amendment guarantees that you can't be prosecuted twice for the same offense. If you're charged with a crime and a jury finds you not guilty, the prosecution doesn't get another shot. Without this protection, the prosecution could simply keep coming after you, and your right to a fair trial would be rendered worthless.
However, there is one major exception to the double-jeopardy rule: sovereign governments can each prosecute you for the same crime. If you were convicted of drug trafficking by a foreign country, the U.S. federal government could still prosecute you for the same drug trafficking activity (assuming they had jurisdiction to do so).
Likewise, because U.S. states are each separate sovereigns, you can be prosecuted for the same conduct in multiple states (again, assuming each has jurisdiction).
The Supreme Court weighs in
In a recent decision, the Supreme Court affirmed this double-jeopardy exception – called the "dual sovereignty doctrine" – as it applies to state and federal governments. The case, Gamble v. United States, involved a felon in possession of a firearm. The defendant was first prosecuted by Alabama state authorities. He was convicted and sentenced to a year in prison. Meanwhile, the feds pursued charges against him for the same act of possessing a firearm. They secured a conviction, and the defendant was sentenced to nearly two years in prison (to run concurrently with his state sentence).
The Supreme Court noted that the double jeopardy clause applies to offenses, not conduct. State and federal authorities can prosecute a defendant for the same underlying conduct. They're not technically the same offense since they involve violations of two separate penal codes. And because the federal government is a separate sovereign from state governments, the dual-sovereignty exception applies.
The impact on Trump's associates
The decision has huge implications for Trump associates who have been convicted on federal charges. It affirms that they can still face criminal prosecution at the state level.
As noted in the Mueller report, Trump has made comments about potentially pardoning three associates who were convicted on federal charges:
Paul Manafort, his former campaign chair
Michael Cohen, his longtime attorney
Michael Flynn, his former National Security Advisor
His presidential pardon power only extends to federal convictions.
In March, the New York State Assembly passed an exception to their state-level prohibition on double jeopardy, clearing the way for charges against Trump associates for criminal activities that took place in that state. (Trump's business and campaign are headquartered in New York.) Manafort is already facing state charges. His defense took a hit with the recent Supreme Court decision; his attorney had sought to dismiss the charges on grounds of double jeopardy.
The decision strikes a powerful blow to Trump's ability to shield his associates. It also sheds light on the judicial dispositions of his two appointees. While Gorsuch wrote a weakly reasoned dissent, Kavanaugh joined in the majority decision upholding the double-jeopardy exception.


Lori Roberts believes one reason Hamilton Elks Country Club has enjoyed a recent run of success in Greater Cincinnati Women's Golf Association events is softball. She and many of her teammates on the Elks played the sport growing up.
"I really think it helps your hand-eye coordination." Robert said.
Roberts served as captain for the Elks team that pulled away from Kenwood Country Club to win the Division I-level championship of the five-event GCWGA Fall Team tournament.
Miami View Golf Club, led by Diane Rottinghaus, took an early lead and held off TPC River's Bend to squeeze out a two-point win in Division II. The Clovernook Country Club team captained by Ellen Shoemaker led Division III the entire way and came up with a five-point win over Stillmeadow Country Club, while Ivy Hills Country Club took advantage of playing the Division IV final round on its home course to match Hamilton Elks for the widest winning margin of the four divisions.
Hamilton Elks rode solid, consistent efforts from its team of Vicki Felver, Stacey Hinkle, Hilda Hodges, Sandy Roark and Tina Davis to the championship, matching the club's Spring Team championship. The Elks team posted a nine-point win over Kenwood in Week Three at Wetherington Golf and Country Club to turn a 2.5-point lead into a 12.5-point bulge. Roberts believes Wetherington's wide-open fairways played to the strengths of her team.
"We're just a bunch of girls who like to play golf," Roberts said.
Ivy Hills Division IV: Carole Hastings, Linda Leigh Ross, Diana Oberschmidt. Also playing in the final match but not pictured was Judy Frey.
The Ivy Hills team of Oberschmidt, Denise Meismer, Linda Leigh Ross, Carole Hastings, Connie Toole and Nicky Wolff led Maketewah Country Club by one point going into the final round at Ivy Hills, where they rolled to a 12-point win. "I think you can say we were pretty confident going into the final round," Oberschmidt said with a smile. "I think most golfers are more comfortable on their home course." Ivy Hills was bolstered by the play of Toole, Oberschmidt said.
"Her game really came together," the captain said.
Clovernook Division III: Cindy Valerius, Mary Pat Lienhart, Ellen Shoemaker, Kristy Herbort.
The Miami View team opened up a 7.5-point lead in Week Two and nursed it through dropping the Week Three and Week Four events to the final. The roster included Kathy Dinkelacker, Debbie Driehaus, Barb Schneider, Lynn Torbeck, Kim Bollinger, Linda Steinriede, Karen Smith, Mary Hanak, Debbie Brennan, Diane Sundrip and Jan Humpert.
Clovernook held a 10.5-point lead through Week III before finishing six points behind Stillmeadow in Week Four and getting back on track with a 7.5-point win in Week Five. Shoemaker's roster consisted of Mary Pat Lienhart, Kristy Herbort, Diana Hodapp, Cindy Valerius, Deanna Ashing, Julie Inman, Karen Mihovk, Karen Campbell, Betty Chriest, JoEllen Nieman, Paulette Homer, Jan Schmid and Patricia Krumdieck.


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The Armenian central bank approved the proposed merger between Armenian Development Bank OJSC and ARARATBANK OJSC, Armbanks reported Dec. 20.
Araratbank will become the legal successor of Armenian Development Bank following the integration.
At the end of 2014, the Armenian central bank increased minimum capital requirement for commercial lenders to 30 billion Armenian drams as of Jan. 1, 2017, from 5 billion drams required at the time, with the move resulting in capital hikes and M&A deals across the local banking sector, the news report said.
As of Dec. 20, US$1 was equivalent to 482.68 Armenian drams.


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