CDC: Miners, construction, food workers smoke most (AP)

ATLANTA � A new government report says construction workers, miners and food service workers are the occupations that smoke the most. Experts say that may have as much to do with education levels as the jobs themselves.

The Centers for Disease Control and Prevention study found 19.6 percent of working adults smoke, but as many as 30 percent in the mining, construction and food service industries smoke. Librarians and teachers smoked the least, at less than 9 percent.

Also, people who work outdoors are less likely to face indoor smoking bans seen in other workplaces.

The study is based on in-person interviews of more than 113,000 working adults in the years 2004 through 2010.

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Online:

CDC report: http://www.cdc.gov/mmwr

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Cantaloupe illnesses and deaths expected to rise (AP)

WASHINGTON � Federal health officials said Wednesday more illnesses and possibly more deaths may be linked to an outbreak of listeria in cantaloupe in coming weeks.

So far, the outbreak has caused at least 72 illnesses � including up to 16 deaths � in 18 states, making it the deadliest food outbreak in the United States in more than a decade.

The heads of the Centers for Disease Control and Prevention and the Food and Drug Administration said consumers who have cantaloupes produced by Jensen Farms in Colorado should throw them out. If they are not sure where the fruit is from, they shouldn't eat it.

Neither the government nor Jensen Farms has supplied a list of retailers who may have sold the fruit. Officials say consumers should ask retailers about the origins of their cantaloupe. If they still aren't sure, they should get rid of it.

"If it's not Jensen Farms, it's OK to eat," said Thomas Frieden, director of the CDC. "But if you can't confirm it's not Jensen Farms, then it's best to throw it out."

Jensen Farms of Holly, Colo. says it shipped cantaloupes to 25 states, though the FDA has said it may be more, and illnesses have been discovered in several states that were not on the shipping list. A spokeswoman for Jensen Farms said the company's product is often sold and resold, so they do not always know where it went.

The recalled cantaloupes may be labeled "Colorado Grown," `'Distributed by Frontera Produce," `'Jensenfarms.com" or "Sweet Rocky Fords." Not all of the recalled cantaloupes are labeled with a sticker, the FDA said. The company said it shipped out more than 300,000 cases of cantaloupes that contained five to 15 melons, meaning the recall involved 1.5 million to 4.5 million pieces of fruit.

The FDA said none of the cantaloupes had been exported, reversing an earlier statement that some of the tainted melons had been shipped abroad.

Frieden and FDA Commissioner Margaret Hamburg said that illnesses are expected for weeks to come because the incubation period for listeria can be a month or even longer. That means that someone who ate contaminated cantaloupe last week may not get sick until next month. Jensen Farms last shipped cantaloupes on Sept. 10. The shelf life is about two weeks.

"We will see more cases likely through October," Hamburg said.

The Food and Drug Administration said state health officials found listeria in cantaloupes taken from Colorado grocery stores and from a victim's home that were grown at Jensen Farms. Matching strains of the disease were found on equipment and cantaloupe samples at Jensen Farms' packing facility in Granada, Colo.

Sherri McGarry, a senior adviser in the FDA's Office of Foods, said the agency is looking at the farm's water supply and possible animal intrusions among other things in trying to figure out how the cantaloupes became contaminated. Listeria bacteria grow in moist, muddy conditions and are often carried by animals.

The health officials said this is the first known outbreak of listeria in cantaloupe. Listeria is generally found in processed meats and unpasteurized milk and cheese, though there have been a growing number of outbreaks in produce. Hamburg called the outbreak a "surprise" and said the agencies are studying it closely to find out how it happened.

Cantaloupe is often the source of outbreaks, however. Frieden said CDC had identified 10 other cantaloupe outbreaks in the last decade, most of them from salmonella.

Listeria is more deadly than well-known pathogens like salmonella and E. coli, though those outbreaks generally cause many more illnesses. Twenty-one people died in an outbreak of listeria poisoning in 1998 traced to contaminated hot dogs and possibly deli meats made by Bil Mar Foods, a subsidiary of Sara Lee Corp. Another large listeria outbreak, in 1985, killed 52 people and was linked to Mexican-style soft cheese.

Listeria generally only sickens the elderly, pregnant women and others with compromised immune systems. The CDC said the median age of those sickened is 78 and that 1 in 5 who contract the disease can die from it. Symptoms include fever and muscle aches, often with other gastrointestinal symptoms.

Unlike many pathogens, listeria bacteria can grow at room temperatures and even refrigerator temperatures. It is hardy and can linger long after the source of the contamination is gone � health officials say people who may have had the contaminated fruit in their kitchens should clean and sanitize any surfaces it may have touched.

The CDC said Tuesday that 13 deaths are linked to the tainted fruit. State and local officials say they are investigating three additional deaths that may be connected.

The death toll released by the CDC Tuesday surpassed the number of deaths linked to an outbreak of salmonella in peanuts almost three years ago. Nine people died in that outbreak. The CDC reported four deaths in New Mexico, two deaths each in Colorado and Texas and one death each in Kansas, Missouri, Nebraska, Oklahoma and Maryland.

New Mexico officials said Tuesday they are investigating a fifth death, while health authorities in Kansas and Wyoming said they too are investigating additional deaths possibly linked to the tainted fruit.

The CDC reported the 72 illnesses and deaths in 18 states. Cases of listeria were reported in California, Colorado, Florida, Illinois, Indiana, Kansas, Maryland, Missouri, Montana, Nebraska, New Mexico, North Dakota, Oklahoma, Texas, Virginia, West Virginia, Wisconsin, and Wyoming. The most illnesses were reported in Colorado, which has seen 15 sickened. Fourteen illnesses were reported in Texas, 10 in New Mexico and eight in Oklahoma.

While most healthy adults can consume listeria with no ill effects, it can kill the elderly and those with compromised immune systems. It is also dangerous to pregnant women because it easily passes through to the fetus. The CDC's Frieden said that two of those sickened were pregnant women but they have since recovered.

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Online:

CDC on cantaloupe outbreak: http://www.cdc.gov/listeria/index.html

FDA on cantaloupe recall: http://www.fda.gov/Food/FoodSafety/CORENetwork/ucm272372.htm

Center for Science and the Public Interest, "Super Safe Your Kitchen": http://www.cspinet.org/new/pdf/safekitchen.pdf

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Find Mary Clare Jalonick on Twitter at http://twitter.com/MCJalonick

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Dementia patients suffer dubious hospitalizations (AP)

One-fifth of Medicare nursing home patients with advanced Alzheimer's or other dementias were sent to hospitals or other nursing homes for questionable reasons in their final months, often enduring tube feeding and intensive care that prolonged their demise, a new study found.

Nursing homes may feel hospital care is warranted when a frail, elderly patient develops swallowing problems, pneumonia or a serious infection, but researchers suspect a different motive for many transfers: money. Medicare pays about three times the normal daily rate for nursing homes to take patients back after a brief hospitalization.

"I think that's unfortunately a factor in what's happening here," said Dr. Joan Teno, a palliative care physician and health policy professor at Brown University. "A lot of this care just feels like in and out, in and out. You really have to question, is the health care system doing a good job or not."

She is a co-author of the study, published in Thursday's New England Journal of Medicine and done with researchers from Harvard University and Dartmouth Medical School.

Among the nearly 475,000 patients studied, 19 percent were moved for questionable reasons. The study provided no evidence that money motivated such transfers or that there was wrongdoing involved. However, the large variation that researchers saw from state to state suggests money may be playing a role.

Rates of such transfers varied from 2 percent in Alaska to more than 37 percent in Louisiana. In McAllen, Texas, 26 percent of study participants had multiple hospitalizations for urinary infections, pneumonia or dehydration � conditions that usually can be treated in a nursing home. That compares to just 1 percent of patients in Grand Junction, Colo.

The researchers used Medicare records from 2000 through 2007 to identify "burdensome" transitions of care: moving patients in the last three days of life, moving them multiple times in the last three months of life, or moving them so they landed in a new nursing home afterward.

Medicaid pays on average $175 per day, depending on the state, for long-term care, but Medicare will pay three times that for skilled nursing care after a patient returns from three days or more in a hospital.

"If you have a nursing home that is operating on a margin, it adds up. It can be a tremendous incentive to hospitalize these people," Teno said.

Researchers found that patients who had a dubious transfer were more likely to have a feeding tube inserted, to spend time in intensive care in the last month of life, to have a severe bedsore or to be enrolled in hospice late (three days or less before they died).

Dubious transfers were more common with black patients, Hispanics and those without advance directives, legal documents spelling out care wishes.

The National Institute on Aging sponsored the study. One author consults for a nursing home system and owns stock in a long-term care information services company.

The study is important because more than 1.6 million Americans live in nursing homes, and nearly one-quarter of people admitted to one after hospitalization wind up back in the hospital within a month, Dr. Joseph Ouslander of Florida Atlantic University in Boca Raton and Dr. Robert Berenson of the Urban Institute in Washington, D.C., wrote in an editorial in the journal. Nursing homes may fear legal liability if they don't hospitalize a very sick patient, they wrote.

However, people with advanced dementia have a terminal condition.

"These are people who are unable to recognize their relatives, they're bed-bound and they're now usually having problems with swallowing. This is a population where the burdens of hospitalization often outweigh the possible benefits," Teno said. "These patients actually do better when they stay in a nursing home," where caregivers and surroundings are familiar, she said.

For families and nursing homes, "it may be difficult to recognize that in fact, this person is in the dying process," said Dr. Michael Malone, medical director of senior services for Aurora Health Care, a network of 15 hospitals in eastern Wisconsin. His 87-year-old father, Wendell Malone, died in January of advanced dementia in a nursing home that managed his care without frequent hospitalizations.

"It provided dignity, it provided comfort for the family," and let him stay in a place and with caregivers he knew, Malone said.

Beth Kallmyer, who runs programs for caregivers for the Alzheimer's Association, said the most important thing is to have a plan in place, with legal documents like "do not hospitalize" directives, before a nursing home has to make a decision about whether to hospitalize someone or instead focus on comfort care and not try to prolong life.

"When the time comes, the family will be able to say `This is what dad wanted,'" Kallmyer said.

She and other experts offered these tips:

_Involve patients in planning their care while they're still able to do so, and make sure wishes like "do not resuscitate" or "do not call 911" are spelled out in legal documents.

_Develop good relationships with nursing home staff and attending physicians so they understand the family's goals of care.

_Consider hospice care when seniors with advanced dementia are admitted.

_Revisit and review the plan whenever there is a change in a loved one's status. Someone may not be end-stage when they enter a nursing home but that can change.

_Seek advice. The Alzheimer's Association has a 24-hour toll-free number, 1-800-272-3900, with counselors to help families.

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Online:

Medical journal: http://www.nejm.org

State reports: http://www.LTCFocUS.org

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Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Lawmakers: CDC to have student concussion protocol (AP)

NUTLEY, N.J. � As awareness continues to grow about sports-related concussions among student athletes, two New Jersey lawmakers say it's time for schools to start following nationwide protocols governing such injuries.

U.S. Sen. Robert Menendez and Rep. Bill Pascrell announced Tuesday that the Centers for Disease Control and Prevention agreed to study and develop national guidelines for managing sports-related concussions for student athletes.

Menendez and Pascrell, both New Jersey Democrats, had sponsored legislation, which passed the House but stalled in the Senate, that would have made such protocols mandatory. Several states, including New Jersey, have laws requiring a physician's approval for a student to return to sports, but Pascrell said there needs to be nationwide guidance for schools and youth sports programs to follow.

"The science may be changing, but that's no excuse for not establishing a protocol," Pascrell said, referring to differing scientific findings on concussions. "We're close to that for our soldiers, we need to be even closer for our children."

Stressing that "every concussion is brain damage," Pascrell said 41 percent of student athletes who suffer concussions return to playing too soon, sometimes with serious or even fatal consequences.

The CDC will convene a panel of experts to define the scope of the protocol, review existing literature, review the current state of science on concussions and have protocols ready for distribution by fall of 2014, according to Pascrell.

"Sports are a great way for kids and teens to stay healthy and this project will help us continue the important work in traumatic brain injuries in sports and other activities," said Dr. Linda C. Degutis of CDC's National Center for Injury Prevention and Control. "CDC's new initiative on pediatric guidelines will work to improve diagnosis and management of brain injuries in younger children and teens who are injured on or off the playing field."

About a dozen states, including New Jersey, have rules related to concussions and brain injuries among student athletes, according to the National Conference of State Legislatures. Other states are considering similar measures.

Concussions are caused by a blow that forces the head to move violently. They can affect memory, judgment, reflexes, speech, balance and muscle coordination and the symptoms become worse if not properly treated. Young people, particularly girls, are more susceptible to long-term repercussions than adults.

Pascrell started pushing for legislation after the October 2008 death of Montclair High school football player Ryne Dougherty. Dougherty reportedly sat out three weeks after suffering a concussion but was cleared to return to playing after taking a test. He collapsed after making a tackle his first game back, and died after suffering a brain hemorrhage.

For years, the CDC has been working on the issue of sports-related concussions, and developed materials for coaches on steps to take if they think a student athlete suffered a concussion. Those steps include removing the athlete from the game or practice, and then having them evaluated by a health care professional with experience in concussions. The advice also suggests not returning the athlete to play until the health professional says it's OK, and telling the student's parents what happened.

But Tuesday's announcement represents something broader. The CDC is putting together an expert panel to discuss possible pediatric guidelines for doctors on how to best diagnose and treat concussions that occur not only on the sports field but also from car accidents, falls and other causes. That might include a look at the type of assessments currently used, although exactly what the panel will examine hasn't been decided.

The announcement was held at Nutley High School in New Jersey, where athletes say the school has adopted a strict policy in recent years on monitoring concussions.

Seventeen-year-old Andre Hamlin has been playing football since he was in the third grade. Now a senior on the football team, he said he's noticed a major change in recent years, with coaches making awareness and testing for concussions mandatory.

Hamlin said all student athletes take a computerized "impact test" of word problems and other questions that test brain function and must be cleared by a doctor before starting any sport.

He said awareness of concussions is now common and that coaches tell players how to avoid concussions by keeping their heads up during football plays.

"It's something that's present throughout the season, our coach emphasizes it," Hamlin said. "If you see a player put their head down incorrectly it kind of gets your skin crawling, `cause that's how you can get a concussion. We tell the younger kids: put your head up, and stay safe out there."

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AP Medical Writer Mike Stobbe in Atlanta contributed to this report.

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Follow Samantha Henry at http://www.twitter.com/SamanthaHenry.

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Study: Dads less likely to die of heart problems (AP)

Fatherhood may be a kick in the old testosterone, but it may also help keep a man alive. New research suggests that dads are a little less likely to die of heart-related problems than childless men are.

The study � by the AARP, the government and several universities � is the largest ever on male fertility and mortality, involving nearly 138,000 men. Although a study like this can't prove that fatherhood and mortality are related, there are plenty of reasons to think they might be, several heart disease experts said.

Marriage, having lots of friends and even having a dog can lower the chance of heart problems and cardiac-related deaths, previous research suggests. Similarly, kids might help take care of you or give you a reason to take better care of yourself.

Also, it takes reasonably good genes to father a child. An inability to do so might mean a genetic weakness that can spell heart trouble down the road.

"There is emerging evidence that male infertility is a window into a man's later health," said Dr. Michael Eisenberg, a Stanford University urologist and fertility specialist who led the study. "Maybe it's telling us that something else is involved in their inability to have kids."

The study was published online Monday by the journal Human Reproduction.

Last week, a study by other researchers of 600 men in the Philippines found that testosterone, the main male hormone, drops after a man becomes a dad. Men who started out with higher levels of it were more likely to become fathers, suggesting that low levels might reflect an underlying health issue that prevents reproduction, Eisenberg said.

In general, higher levels of testosterone are better, but too much or too little can cause HDL, or "good cholesterol," to fall � a key heart disease risk factor, said Dr. Robert Eckel, past president of the American Heart Association and professor of medicine at the University of Colorado, Denver.

"This is a hot topic," Eckel said. "I like this study because I have five children," he joked, but he said many factors such as job stress affect heart risks and the decision to have children.

Researchers admit they couldn't measure factors like stress, but they said they did their best to account for the ones they could. They started with more than 500,000 AARP members age 50 and over who filled out periodic surveys starting in the 1990s for a long-running research project sponsored by the National Cancer Institute.

For this study, researchers excluded men who had never been married so they could focus on those most likely to have the intent and opportunity to father a child. Men with cancer or heart disease also were excluded to compare just men who were healthy when the study began.

Of the remaining 137,903 men, 92 percent were fathers and half had three or more children. After an average of 10 years of follow-up, about 10 percent had died. Researchers calculated death rates according to the number of children, and adjusted for differences in smoking, weight, age, household income and other factors.

They saw no difference in death rates between childless men and fathers. However, dads were 17 percent less likely to have died of cardiovascular causes than childless men were.

Now for all the caveats.

Researchers don't know how many men were childless by choice and not because of a fertility problem.

They don't know what fertility problems the men's partners may have had that could have left them childless.

They didn't have cholesterol or blood pressure information on the men � key heart risk factors.

Less than 5 percent of participants were blacks or other minorities, so the results may not apply to them.

All those questions aside, however, some prominent heart experts were reassured by the study's large size and the steps researchers took to adjust for heart disease risk factors.

"I think there's something there," and social science supports the idea that children can lower heart risks, said Dr. Eric Topol, a cardiologist and genetics expert at Scripps Health in La Jolla, Calif. "Whether it's with a pet, a spouse or social interaction ... all those things are associated with better outcomes."

Dr. Daniel Rader, director of preventive cardiology at the University of Pennsylvania, said: "It's biologically plausible that there's a connection," but the reduced risk attributed to having children "is pretty modest."

Men often ask him what they can do to keep from dying of a heart attack, he said.

"I'm not really prepared to, on the basis of this, tell them to start having a few kids," Rader said.

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Online:

Medical journal: http://humrep.oxfordjournals.org/content/early/recent

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Marilynn Marchione can be followed at http://twitter.com/MMarchioneAP

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Decade after anthrax attacks, worry over stockpile (AP)

WASHINGTON � Anthrax vaccine � check. Antibiotics � check. A botulism treatment � check. Smallpox vaccine � check.

Ten years after the anthrax attacks brought home the reality of bioterrorism, the nation has a stockpile of some basic tools to fight back against a few of the threats that worry defense experts the most.

These defenses are not just gathering dust awaiting the next attack. In August, a Minneapolis hospital dipped into the stockpile to treat a critically ill patient � a tourist who, somewhere on his Midwest vacation, had the extraordinary bad luck to breathe anthrax spores that naturally linger in the dirt in parts of the country. The man, who survived, received a kind of medication not available in October 2001 when anthrax spores sent through the mail killed five people and sickened 17.

But there's wide concern that the nation's arsenal hasn't grown fast enough. A decade later, there are no treatments for a number of bugs on the worry list, and little to offer for other threats like a radiation emergency. Even a long-promised next-generation anthrax vaccine, that would be easier to produce, hasn't arrived yet. Nor is there information on how to treat children.

"Where are the countermeasures?" advisers to the Department of Health and Human Services asked in a critical report last year.

There are some: There's enough smallpox vaccine for everyone, plus some of a specially formulated version safe for cancer patients and others with weak immune systems. There's an improved version of the decades-old anthrax vaccine used in 2001. There are a few treatments for the toxins produced by anthrax and botulism, and a smallpox treatment is due soon.

But federal health officials are working to jumpstart production of more countermeasures and they say that more than 80 candidates are in advanced development. Over the past year, the goal has evolved into a push for more multiuse therapies, products that work not just for biodefense but for everyday health problems, too.

That's a major shift that should entice more big drug companies to the field, says Dr. Robin Robinson, who heads the federal Biomedical Advanced Research and Development Authority, or BARDA. It funds late-stage research of promising countermeasures.

Consider: BARDA just agreed to help pay for drug giant GlaxoSmithKline's testing of a novel antibiotic that might fight bioterrorism germs like plague � as well as certain hospital-spread bacteria that cause such problems as pneumonia in the already seriously ill.

So-called broad-spectrum antibiotics that can kill more than one kind of bacteria aren't unusual � this one just targets some hard-to-treat types in a new way.

The next step: Scientists are beginning to create the first broad-spectrum antivirals, medicines that would treat more than one kind of virus. Rather than having an anti-flu drug and a separate anti-AIDS drug, the goal is to have a single injection that could treat those viruses plus the gruesome Ebola virus and a few more for good measure.

It's early work, still years away, cautions Dr. Michael Kurilla, biodefense research chief at the National Institute of Allergy and Infectious Diseases. But one of the antivirals is a direct result of biodefense research to understand how viruses infect � specifically, the Nipah virus that was the model for the even-scarier fictional bug in the new movie "Contagion."

And these multipurpose antivirals are a huge goal because if they pan out, the next time a brand-new virus emerges � like the respiratory SARS bug in 2003 � treatments might not have to be started from scratch.

"We feel very excited and confident that what we're working on ... can change the whole paradigm of how we approach infectious diseases," Kurilla says.

The U.S. has invested $67 billion in biosecurity since 2001, according to research by the Center for Biosecurity at the University of Pittsburgh Medical Center.

Most of that wasn't solely for biodefense but went to broader health programs that are as crucial for dealing with natural crises � like the 2009 swine flu global epidemic � as for dealing with manmade ones, says center director Dr. Thomas Inglesby. These include scientific research, beefing up struggling public health departments to better detect and treat emerging outbreaks, and training hospitals in disaster preparedness.

Inglesby worries that the economic crisis imperils those gains � public health funding already has been cut � and will further slow the countermeasure hunt. A program named BioShield that buys countermeasures for the stockpile expires in 2013 unless Congress reauthorizes it. It's time, he says, for the government to spell out its countermeasure priorities and how to reach them.

Meanwhile, what if another anthrax attack happened? No more scrambling to buy antibiotics: 60 million 60-day treatment courses are stockpiled, Robinson says, and the plan is for the post office to get the first doses to people's homes.

Sometimes antibiotics aren't enough. In a severe infection, the germs can produce dangerous toxins that spread in the bloodstream. So also in the stockpile are two experimental toxin-clearing treatments, to be used if the immune system alone can't battle the toxin.

In August, Minnesota's sick tourist became the 19th person in the world ever treated with one of them � immune globulin culled from the blood of anthrax-vaccinated soldiers, says Dr. Mark Sprenkle of Hennepin County Medical Center. It's hard to know how much the drug contributed to the man's recovery, Sprenkle says, but his patient's toxin levels did drop more quickly after he began using it.

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EDITOR'S NOTE � Lauran Neergaard covers health and medical issues for The Associated Press.

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