Baby Born with Heart Outside Her Chest Goes Home from Hospital

By Dahvi Shira

01/24/2013 at 06:40 PM EST

Ashley and Audrina Cardenas

Three-month-old Audrina Cardenas is a survivor.

The infant, delivered on Oct. 15 with a rare genetic deformity called "ectopia cordis," was born with part of her heart outside of her body. Following a successful surgery in November, Cardenas finally left the hospital on Wednesday.

At the time of her procedure, the Texas Children's Hospital in Houston released a statement explaining, "A multidisciplinary team of surgeons saved Audrina's life during a miraculous six-hour, open-heart surgery where they reconstructed her chest cavity to make space for the one-third of her heart that was outside of her body."

Cardenas's mother Ashley told ABCNews.com that she knew about her daughter's condition when she was 16 weeks pregnant.

"They gave me the option to terminate the pregnancy [or] continue with the pregnancy and do something called comfort care at the time of delivery, where instead of doing anything painful to her or do surgery, they let you spend as much time with her until she passes, or opt for a high-risk surgery to help repair the heart," Ashley Cardenas said.

Although she's been released from the hospital, Audrina will still be on oxygen and use a feeding tube, according to her mom, who spoke to HLN affiliate KTRK.

With Audrina wearing a pink chest shield made by doctors, Ashley said, "She doesn't have the sternum. She doesn't have anything over her heart besides the skin and a little muscle that they put over, so this is very important for her to wear. Especially for a car seat, the straps go right on her heart, and if she didn't have anything hard, it would damage her heart."

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Penalty could keep smokers out of health overhaul

WASHINGTON (AP) — Millions of smokers could be priced out of health insurance because of tobacco penalties in President Barack Obama's health care law, according to experts who are just now teasing out the potential impact of a little-noted provision in the massive legislation.

The Affordable Care Act — "Obamacare" to its detractors — allows health insurers to charge smokers buying individual policies up to 50 percent higher premiums starting next Jan. 1.

For a 55-year-old smoker, the penalty could reach nearly $4,250 a year. A 60-year-old could wind up paying nearly $5,100 on top of premiums.

Younger smokers could be charged lower penalties under rules proposed last fall by the Obama administration. But older smokers could face a heavy hit on their household budgets at a time in life when smoking-related illnesses tend to emerge.

Workers covered on the job would be able to avoid tobacco penalties by joining smoking cessation programs, because employer plans operate under different rules. But experts say that option is not guaranteed to smokers trying to purchase coverage individually.

Nearly one of every five U.S. adults smokes. That share is higher among lower-income people, who also are more likely to work in jobs that don't come with health insurance and would therefore depend on the new federal health care law. Smoking increases the risk of developing heart disease, lung problems and cancer, contributing to nearly 450,000 deaths a year.

Insurers won't be allowed to charge more under the overhaul for people who are overweight, or have a health condition like a bad back or a heart that skips beats — but they can charge more if a person smokes.

Starting next Jan. 1, the federal health care law will make it possible for people who can't get coverage now to buy private policies, providing tax credits to keep the premiums affordable. Although the law prohibits insurance companies from turning away the sick, the penalties for smokers could have the same effect in many cases, keeping out potentially costly patients.

"We don't want to create barriers for people to get health care coverage," said California state Assemblyman Richard Pan, who is working on a law in his state that would limit insurers' ability to charge smokers more. The federal law allows states to limit or change the smoking penalty.

"We want people who are smoking to get smoking cessation treatment," added Pan, a pediatrician who represents the Sacramento area.

Obama administration officials declined to be interviewed for this article, but a former consumer protection regulator for the government is raising questions.

"If you are an insurer and there is a group of smokers you don't want in your pool, the ones you really don't want are the ones who have been smoking for 20 or 30 years," said Karen Pollitz, an expert on individual health insurance markets with the nonpartisan Kaiser Family Foundation. "You would have the flexibility to discourage them."

Several provisions in the federal health care law work together to leave older smokers with a bleak set of financial options, said Pollitz, formerly deputy director of the Office of Consumer Support in the federal Health and Human Services Department.

First, the law allows insurers to charge older adults up to three times as much as their youngest customers.

Second, the law allows insurers to levy the full 50 percent penalty on older smokers while charging less to younger ones.

And finally, government tax credits that will be available to help pay premiums cannot be used to offset the cost of penalties for smokers.

Here's how the math would work:

Take a hypothetical 60-year-old smoker making $35,000 a year. Estimated premiums for coverage in the new private health insurance markets under Obama's law would total $10,172. That person would be eligible for a tax credit that brings the cost down to $3,325.

But the smoking penalty could add $5,086 to the cost. And since federal tax credits can't be used to offset the penalty, the smoker's total cost for health insurance would be $8,411, or 24 percent of income. That's considered unaffordable under the federal law. The numbers were estimated using the online Kaiser Health Reform Subsidy Calculator.

"The effect of the smoking (penalty) allowed under the law would be that lower-income smokers could not afford health insurance," said Richard Curtis, president of the Institute for Health Policy Solutions, a nonpartisan research group that called attention to the issue with a study about the potential impact in California.

In today's world, insurers can simply turn down a smoker. Under Obama's overhaul, would they actually charge the full 50 percent? After all, workplace anti-smoking programs that use penalties usually charge far less, maybe $75 or $100 a month.

Robert Laszewski, a consultant who previously worked in the insurance industry, says there's a good reason to charge the maximum.

"If you don't charge the 50 percent, your competitor is going to do it, and you are going to get a disproportionate share of the less-healthy older smokers," said Laszewski. "They are going to have to play defense."

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Online:

Kaiser Health Reform Subsidy Calculator — http://healthreform.kff.org/subsidycalculator.aspx

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S&P rises for seventh day but 1,500 too steep a climb

NEW YORK (Reuters) - The smallest of gains gave the Standard & Poor's 500 its seventh straight winning day on Thursday, but the index failed to hold above the 1,500 line, restrained by Apple's worst day in more than four years.

Apple Inc slid 12.4 percent to $450.50 a day after it posted revenue that missed Wall Street's forecast as iPhone sales were poorer than expected.

The sharp drop wiped out nearly $60 billion in Apple's market capitalization to less than $423 billion, leaving the company vulnerable to losing its status as the most valuable U.S. company to second-place ExxonMobil , at $416.5 billion.

The S&P 500, however, managed to hit its longest winning streak since October 2006.

"The market has sent the message it is no longer driven by the whims of Apple," said Ken Polcari, director of the NYSE floor division at O'Neil Securities in New York.

The S&P 500 briefly traded above 1,500 for the first time since December 12, 2007, but failed to hold above it, indicating that momentum is waning and a pullback is in the charts.

"If the market had a little bit more excitement to it, momentum players would have jumped after it broke through 1,500. Investors know the market is a little bit ahead of itself," Polcari said.

Economic data helped buoy equities as U.S. factory activity grew the most in nearly two years in January and new claims for jobless benefits dropped to a five-year low last week, giving surprisingly strong signals on the economy's pulse.

At the same time, Chinese manufacturing grew this month at the fastest pace in about two years, while data suggesting German growth picked up boosted hopes for a euro-zone recovery.

"PMI in Asia, Europe, and obviously, here in the United States, is moving in the right direction, and that's stuff people should be excited about," Polcari said.

The Dow Jones industrial average <.dji> rose 46 points or 0.33 percent, to 13,825.33 at the close. The S&P 500 <.spx> inched up just 0.01 of a point, or 0 percent, to finish at 1,494.82. The Nasdaq Composite <.ixic> dropped 23.29 points or 0.74 percent, to end at 3,130.38, with most of that loss on Apple's slide.

The broader Russell 2000 index <.rut> also hit a milestone as it closed above 900 points for the first time.

Video streaming service Netflix Inc surprised Wall Street with a quarterly profit after it added nearly 4 million customers in the United States and abroad. Netflix shares surged 42.2 percent to $146.86, its biggest percentage jump ever.

Earnings have helped drive the stock market's recent rally. Thomson Reuters data through early Thursday showed that of the 133 S&P 500 companies that have reported earnings so far, 66.9 percent have exceeded expectations - above the 65 percent average over the past four quarters.

About 6.8 billion shares changed hands on the New York Stock Exchange, the Nasdaq and NYSE MKT, below the daily average during January 2012 of about 6.93 billion shares.

Roughly five issues rose for every four that fell on both the NYSE and Nasdaq.

(Editing by Jan Paschal)

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North Korea to target U.S. with nuclear, rocket tests

SEOUL (Reuters) - North Korea said on Thursday it would carry out further rocket launches and a nuclear test that would target the United States, dramatically stepping up its threats against a country it called its "sworn enemy".

The announcement by the country's top military body came a day after the U.N. Security Council agreed to a U.S.-backed resolution to censure and sanction North Korea for a rocket launch in December that breached U.N. rules.

North Korea is not believed to have the technology to deliver a nuclear warhead capable of hitting the continental United States, although its December launch showed it had the capacity to deliver a rocket that could travel 10,000 km (6,200 miles), potentially putting San Francisco in range, according to an intelligence assessment by South Korea.

"We are not disguising the fact that the various satellites and long-range rockets that we will fire and the high-level nuclear test we will carry out are targeted at the United States," North Korea's National Defence Commission said, according to state news agency KCNA.

North Korea is believed by South Korea and other observers to be "technically ready" for a third nuclear test, and the decision to go ahead rests with leader Kim Jong-un, who pressed ahead with the December rocket launch in defiance of the U.N. sanctions.

China, the one major diplomatic ally of the isolated and impoverished North, agreed to the U.S.-backed resolution and it also supported resolutions in 2006 and 2009 after Pyongyang's two earlier nuclear tests.

Thursday's statement by North Korea represents a huge challenge to Beijing as it undergoes a leadership transition, with Xi Jinping due to take office in March.

China's Foreign Ministry called for calm and restraint and a return to six-party talks, but effectively singled out North Korea, urging the "relevant party" not to take any steps that would raise tensions.

"We hope the relevant party can remain calm and act and speak in a cautious and prudent way and not take any steps which may further worsen the situation," ministry spokesman Hong Lei told reporters at a regular press briefing.

North Korea has rejected proposals to restart the talks aimed at reining in its nuclear capacity. The United States, China, Russia, Japan and the two Koreas are the six parties involved.

"After all these years and numerous rounds of six-party talks we can see that China's influence over North Korea is actually very limited. All China can do is try to persuade them not to carry out their threats," said Cai Jian, an expert on Korea at Fudan University in Shanghai.

Analysts said the North could test as early as February as South Korea prepares to install a new, untested president or that it could choose to stage a nuclear explosion to coincide with former ruler Kim Jong-il's Feb 16 birthday.

"North Korea will have felt betrayed by China for agreeing to the latest U.N. resolution and they might be targeting (China) as well (with this statement)," said Lee Seung-yeol, senior research fellow at Ewha Institute of Unification Studies in Seoul.

U.S. URGES NO TEST

Washington urged North Korea not to proceed with a third test just as the North's statement was published on Thursday.

"Whether North Korea tests or not is up to North Korea," Glyn Davies, the top U.S. envoy for North Korean diplomacy, said in the South Korean capital of Seoul.

"We hope they don't do it. We call on them not to do it," Davies said after a meeting with South Korean officials. "This is not a moment to increase tensions on the Korean peninsula."

The North was banned from developing missile and nuclear technology under sanctions dating from its 2006 and 2009 nuclear tests.

A South Korean military official said the concern now is that Pyongyang could undertake a third nuclear test using highly enriched uranium for the first time, opening a second path to a bomb.

North Korea's 2006 nuclear test using plutonium produced a puny yield equivalent to one kiloton of TNT - compared with 13-18 kilotons for the Hiroshima bomb - and U.S. intelligence estimates put the 2009 test's yield at roughly two kilotons

North Korea is estimated to have enough fissile material for about a dozen plutonium warheads, although estimates vary, and intelligence reports suggest that it has been enriching uranium to supplement that stock and give it a second path to the bomb.

According to estimates from the Institute for Science and International Security from late 2012, North Korea could have enough weapons grade uranium for 21-32 nuclear weapons by 2016 if it used one centrifuge at its Yongbyon nuclear plant to enrich uranium to weapons grade.

North Korea has not yet mastered the technology needed to make a nuclear warhead small enough for an intercontinental missile, most observers say, and needs to develop the capacity to shield any warhead from re-entry into the earth's atmosphere.

North Korea gave no time-frame for the coming test and often employs harsh rhetoric in response to U.N. and U.S. actions that it sees as hostile.

The bellicose statement on Thursday appeared to dent any remaining hopes that Kim Jong-un, believed to be 30 years old, would pursue a different path from his father, Kim Jong-il, who oversaw the country's military and nuclear programs.

The older Kim died in December 2011.

"The UNSC (Security Council) resolution masterminded by the U.S. has brought its hostile policy towards the Democratic Peoples Republic of Korea (North Korea) to its most dangerous stage," the commission was quoted as saying.

(Additional reporting by Christine Kim in SEOUL, Ben Blanchard and Sui-Lee Wee in Beijing; Writing by David Chance; Editing by Raju Gopalakrishnan and Ron Popeski)

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Women have caught up to men on lung cancer risk

Smoke like a man, die like a man.

U.S. women who smoke today have a much greater risk of dying from lung cancer than they did decades ago, partly because they are starting younger and smoking more — that is, they are lighting up like men, new research shows.

Women also have caught up with men in their risk of dying from smoking-related illnesses. Lung cancer risk leveled off in the 1980s for men but is still rising for women.

"It's a massive failure in prevention," said one study leader, Dr. Michael Thun of the American Cancer Society. And it's likely to repeat itself in places like China and Indonesia where smoking is growing, he said. About 1.3 billion people worldwide smoke.

The research is in Thursday's New England Journal of Medicine. It is one of the most comprehensive looks ever at long-term trends in the effects of smoking and includes the first generation of U.S. women who started early in life and continued for decades, long enough for health effects to show up.

The U.S. has more than 35 million smokers — about 20 percent of men and 18 percent of women. The percentage of people who smoke is far lower than it used to be; rates peaked around 1960 in men and two decades later in women.

Researchers wanted to know if smoking is still as deadly as it was in the 1980s, given that cigarettes have changed (less tar), many smokers have quit, and treatments for many smoking-related diseases have improved.

They also wanted to know more about smoking and women. The famous surgeon general's report in 1964 said smoking could cause lung cancer in men, but evidence was lacking in women at the time since relatively few of them had smoked long enough.

One study, led by Dr. Prabhat Jha of the Center for Global Health Research in Toronto, looked at about 217,000 Americans in federal health surveys between 1997 and 2004.

A second study, led by Thun, tracked smoking-related deaths through three periods — 1959-65, 1982-88 and 2000-10 — using seven large population health surveys covering more than 2.2 million people.

Among the findings:

— The risk of dying of lung cancer was more than 25 times higher for female smokers in recent years than for women who never smoked. In the 1960s, it was only three times higher. One reason: After World War II, women started taking up the habit at a younger age and began smoking more.

—A person who never smoked was about twice as likely as a current smoker to live to age 80. For women, the chances of surviving that long were 70 percent for those who never smoked and 38 percent for smokers. In men, the numbers were 61 percent and 26 percent.

—Smokers in the U.S. are three times more likely to die between ages 25 and 79 than non-smokers are. About 60 percent of those deaths are attributable to smoking.

—Women are far less likely to quit smoking than men are. Among people 65 to 69, the ratio of former to current smokers is 4-to-1 for men and 2-to-1 for women.

—Smoking shaves more than 10 years off the average life span, but quitting at any age buys time. Quitting by age 40 avoids nearly all the excess risk of death from smoking. Men and women who quit when they were 25 to 34 years old gained 10 years; stopping at ages 35 to 44 gained 9 years; at ages 45 to 54, six years; at ages 55 to 64, four years.

—The risk of dying from other lung diseases such as emphysema and chronic bronchitis is rising in men and women, and the rise in men is a surprise because their lung cancer risk leveled off in 1980s.

Changes in cigarettes since the 1960s are a "plausible explanation" for the rise in non-cancer lung deaths, researchers write. Most smokers switched to cigarettes that were lower in tar and nicotine as measured by tests with machines, "but smokers inhaled more deeply to get the nicotine they were used to," Thun said. Deeper inhalation is consistent with the kind of lung damage seen in the illnesses that are rising, he said.

Scientists have made scant progress against lung cancer compared with other forms of the disease, and it remains the leading cause of cancer deaths worldwide. More than 160,000 people die of it in the U.S. each year.

The federal government, the Canadian Institutes of Health Research, the Bill and Melinda Gates Foundation, the cancer society and several universities paid for the new studies. Thun testified against tobacco companies in class-action lawsuits challenging the supposed benefits of cigarettes with reduced tar and nicotine, but he donated his payment to the cancer society.

Smoking needs more attention as a health hazard, Dr. Steven A. Schroeder of the University of California, San Francisco, wrote in a commentary in the journal.

"More women die of lung cancer than of breast cancer. But there is no 'race for the cure' for lung cancer, no brown ribbon" or high-profile advocacy groups for lung cancer, he wrote.

Kathy DeJoseph, 62, of suburban Atlanta, finally quit smoking after 40 years — to qualify for lung cancer surgery last year.

"I tried everything that came along, I just never could do it," even while having chemotherapy, she said.

It's a powerful addiction, she said: "I still every day have to resist wanting to go buy a pack."

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Online:

American Cancer Society: http://www.cancer.org

National Cancer Institute: http://www.cancer.gov/cancertopics/tobacco/smoking and http://www.cancer.gov/cancertopics/types/lung

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

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

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S&P up for sixth day, Apple slip could halt rally

NEW YORK (Reuters) - The S&P 500 rose for a sixth day on Wednesday after stronger-than-expected profits from IBM and Google but the rally could be halted as Apple's after-hours miss sent its shares lower.

The S&P was just 4.7 percent from its all-time closing high as IBM's and Google's earnings, released after Tuesday's close, followed on the heels of stronger U.S. economic data.

"People were kind of nervous about earnings coming into this quarter but numbers have shown so far strength in earnings," said King Lip, chief investment officer at Baker Avenue Asset Management in San Francisco.

But Apple , still the largest U.S. publicly traded company, fell 8 percent in extended trading after sales of its flagship iPhone came in below analyst targets and quarterly revenue slightly missed Wall Street expectations.

"One thing that stands out is the company's ballooning balance sheet, where they now have $137 billion dollars in cash and investments," said Michael Sheldon, chief market strategist at RDM Financial in Westport, Connecticut. "You've got to wonder when they're going to put some more of that to work."

Declining issues beat advancers in both the NYSE and Nasdaq during regular market hours, in a sign the market's rally may be overstretched. The broad Russell 2000 index <.rut> closed the day down 0.3 percent after earlier hitting and intraday historic high just below 900 points.

Shares in IBM Corp , the world's largest technology services company, climbed 4.4 percent during regular market hours to $204.72, providing just about all of the Dow's 67-point gain.

Also helping the tech sector was a 5.5 percent jump in Google Inc to $741.50. The Internet search company reported its core business outpaced expectations and revenue was higher than expected.

The S&P technology sector <.splrct> rose 1.2 percent.

The Dow Jones industrial average <.dji> rose 67.12 points or 0.49 percent, to 13,779.33, the S&P 500 <.spx> gained 2.25 points or 0.15 percent, to 1,494.81, and the Nasdaq Composite <.ixic> added 10.49 points or 0.33 percent, to 3,153.67.

The benchmark S&P 500 is a mere 0.35 percent away from hitting 1,500, a level not seen since December 12, 2007.

S&P 500 futures fell 4.1 points, or 0.3 percent, while Nasdaq 100 futures fell 20 points or 0.7 percent.

Netflix shares soared 32 percent, above $136, after the video subscription service said it added subscribers in the United States and abroad and posted a quarterly profit.

LED maker Cree Inc jumped 22 percent to $40.85 after it forecast a higher-than-expected third-quarter profit, and reported results above analysts' estimates.

Upscale leather goods maker Coach Inc plunged 16.4 percent to $50.75 after reporting sales that missed expectations.

Clearing a market hurdle, the U.S. House of Representatives passed a Republican-led plan to extend the country's borrowing authority until mid May. This delays a confrontation in Congress similar to one in 2011, which generated a stalemate that triggered the first-ever U.S. debt rating downgrade.

Thomson Reuters data through Wednesday showed that of the 99 S&P 500 companies that have reported earnings so far, 67.7 percent have topped expectations, above the 65 percent average beat over the past four quarters.

Overall, S&P 500 fourth-quarter earnings rose 2.8 percent, according to Thomson Reuters data. That estimate is above the 1.9 percent forecast at the start of earnings season.

Top U.S. manufacturers sounded a confident note about their expectations for 2013 on Wednesday as fears of the year-end "fiscal cliff" faded into memory.

In the regular session, about 6.1 billion shares changed hands on the New York Stock Exchange, the Nasdaq and NYSE MKT, below the 2012 daily average of about 6.45 billion.

On the NYSE, roughly 15 issues fell for every 14 that rose and on Nasdaq seven declined for every five gainers.

(Reporting by Rodrigo Campos, additional reporting by Caroline Valetkevitch; Editing by Nick Zieminski and Diane Craft)

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Cameron promises Britons vote on EU exit

LONDON (Reuters) - Prime Minister David Cameron promised Britons a vote on quitting the European Union, rattling London's biggest allies and some investors by raising the prospect of uncertainty and upheaval.

Cameron announced on Wednesday that the referendum would be held by the end of 2017 - provided he wins a second term - and said that while Britain did not want to retreat from the world, public disillusionment with the bloc was at "an all-time high".

"It is time for the British people to have their say. It is time for us to settle this question about Britain and Europe," Cameron said in a speech, adding that his Conservative party would campaign for the 2015 parliamentary election on a promise to renegotiate the terms of Britain's EU membership.

"When we have negotiated that new settlement, we will give the British people a referendum with a very simple in or out choice to stay in the European Union on these new terms; or come out altogether. It will be an in-out referendum."

A referendum would mark the second time British voters have had a direct say on the issue. In 1975, they decided by a wide margin to stay in, two years after the country had joined.

Most recent opinion polls have shown a slim majority would vote to leave amid bitter disenchantment, fanned by a hostile press, about the EU's perceived influence on the British way of life. However, a poll this week showed a majority for staying.

Cameron's position is fraught with uncertainty. He must come from behind to win the next election, secure support from the EU's 26 other states for a new British role, and hope those countries can persuade their voters to back the changes.

He also avoided saying exactly what he would do if he failed to win concessions in Europe, as many believe is likely.

Critics, notably among business leaders worried about the effect on investment, say that for years before a vote, Britain may slip into a dangerous and damaging limbo that could leave it adrift or effectively pushed out of the EU.

The United States, a close ally, is also uneasy about the plan, believing it will dilute Britain's international clout. President Barack Obama told Cameron last week that Washington valued "a strong UK in a strong European Union" and the White House said on Wednesday it believed Britain's membership of the EU was mutually beneficial.

Some of Britain's European partners were also anxious and told Cameron on Wednesday his strategy reflected a selfish and ignorant attitude. However, Angela Merkel, the leader of EU paymaster Germany, was quick to say she was ready to discuss Cameron's ideas.

FRENCH "NON"

French Foreign Minister Laurent Fabius was less diplomatic: "If Britain wants to leave Europe, we will roll out the red carpet," he quipped, echoing words Cameron used recently to urge France's rich to escape high taxes and move to Britain.

French President Francois Hollande repeated his refusal of special deals: "What I will say, speaking for France, and as a European, is that it isn't possible to bargain over Europe to hold this referendum," he said. "Europe must be taken as it is.

"One can have it modified in future but one cannot propose reducing or diminishing it as a condition of staying in."

Italian Prime Minister Mario Monti was more positive. He said he agreed with Cameron on the need to make the EU more innovative and welcomed the idea of a British referendum, saying he thought Britons would ultimately vote to stay in the bloc.

Billed by commentators as the most important speech of Cameron's career, his referendum promise ties him firmly to an issue that has bedeviled a generation of Conservative leaders.

In the past, he has been careful to avoid bruising partisan fights over Europe, an issue that undid the last two Conservative prime ministers, John Major and Margaret Thatcher.

His speech appeared to pacify a powerful Euroskeptic wing inside his own party, but deepen rifts with the Liberal Democrats, the junior partners in his coalition. Their leader, Deputy Prime Minister Nick Clegg, said the plan would undermine a fragile economic recovery.

Sterling fell to its lowest in nearly five months against the dollar on Wednesday as Cameron was speaking.

"BREXIT"?

Cameron said he would take back powers from Brussels, saying later in parliament that, when it came to employment, social and environmental legislation, "Europe has gone far too far".

But such a clawback - still the subject of an internal audit to identify which specific powers he should target for repatriation to London - is likely to be easier said than done.

If Cameron wins re-election but then fails to renegotiate Britain's membership of the EU, a 'Brexit' could loom.

Business leaders have warned that years of doubt over Britain's EU membership would damage the $2.5 trillion economy and cool the investment climate.

"Having a referendum creates more uncertainty and we don't need that," Martin Sorrell, chief executive of advertising giant WPP, told the World Economic Forum in Davos. "This is a political decision. This is not an economic decision.

"This isn't good news. You added another reason why people will postpone investment decisions."

Cameron has been pushed into taking such a strong position partly by the rise of the UK Independence Party, which favors complete withdrawal from the EU and has climbed to third in the opinion polls, mainly at the expense of the Conservatives.

"All he's trying to do is to kick the can down the road and to try and get UKIP off his back," said UKIP leader Nigel Farage.

Euroskeptics in Cameron's party, who have threatened to stir up trouble for the premier, were thrilled by the speech.

Conservative lawmaker Peter Bone called it "a terrific victory" that would unify 98 percent of the party. "He's the first prime minister to say he wants to bring back powers from Brussels," Bone told Reuters. "It's pretty powerful stuff".

Whether Cameron holds the referendum remains as uncertain as the Conservatives' chances of winning the election. They trail the opposition Labour party in opinion polls, and the coalition is grappling with a stagnating economy as it pushes through unpopular public spending cuts to reduce a large budget deficit.

Labour leader Ed Miliband said on Wednesday his party did not want an in-or-out referendum.

EU REFORM

Cameron said he would campaign for Britain to stay in the EU "with all my heart and soul", provided he secured the reforms he wants. He made clear the Union must become less bureaucratic and focus more on free trade.

It was riskier to maintain the status quo than to change, he said: "The biggest danger to the European Union comes not from those who advocate change, but from those who denounce new thinking as heresy," he said.

Asked whether, if he did not succeed in his renegotiation strategy, would recommend a vote to take Britain out, he said only: "I want to see a strong Britain in a reformed Europe.

"We have a very clear plan. We want to reset the relationship. We will hold that referendum. We will recommend that resettlement to the British people."

Cameron said the euro zone debt crisis was forcing the bloc to change and that Britain would fight to make sure new rules were fair to the 10 countries that do not use the common currency, of which Britain is the largest.

Democratic consent for the EU in Britain was now "wafer thin", he said:

"Some people say that to point this out is irresponsible, creates uncertainty for business and puts a question mark over Britain's place in the European Union. But the question mark is already there: ignoring it won't make it go away."

A YouGov opinion poll on Monday showed that more people wanted to stay in the EU than leave it, the first such result in many months. But it was unclear whether that result was a blip.

Paul Chipperfield, a 53-year-old management consultant, said he liked the strategy: "Cameron's making the right move because I don't think we've had enough debate in this country," he said.

"We should be part of the EU but the EU needs to recognize that not everybody's going to jump on the same bandwagon."

Asked after the speech whether other EU countries would agree to renegotiate Britain's membership, Cameron said he was an optimist and that there was "every chance of success".

"I don't want Britain to leave the EU," he told parliament later. "I want Britain to reform the EU."

In the 1975 referendum, just over 67 percent voted to stay inside with nearly 33 percent against.

(Additional reporting by Paul Taylor in Davos, Alexandra Hudson in Berlin, Brenda Goh in London, Jeff Mason in Washington and James Mackenzie in Rome; Editing by Guy Faulconbridge, David Stamp and Alastair Macdonald)

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PEOPLE's Music Critic: Why We're Upset About Beyoncé's Lip-Synching Drama

By Chuck Arnold

01/22/2013 at 08:40 PM EST

Did she lip-synch or didn't she?

That's the question surrounding Beyoncé after reports surfaced that she didn't sing "The Star-Spangled Banner" live at yesterday's presidential inauguration.

A spokesperson for the U.S. Marine Band, which backed the pop diva at the ceremony, said Tuesday that Mrs. Jay-Z decided to use a previously recorded vocal track before delivering the national anthem, but later on another spokesperson, this one for the Pentagon, said there was no way of knowing whether the 16-time Grammy winner was guilty of lip-synching or not.

Should it matter? Let's remember that Whitney Houston, in what is widely considered one of the best renditions of "The Star-Spangled Banner" of all time, didn't sing it live either at the 1991 Super Bowl.

There are all sorts of technical reasons why it can be challenging to perform a song as difficult as this on such a large scale, and there are many extenuating circumstances that could have played a role in any decision to lip-synch. Certainly no one is questioning whether Beyoncé – who, in removing her earpiece midway through, may have been experiencing audio problems – has the chops to sing it.

Lip-synching – or at least singing over pre-recorded vocal tracks – has long been acceptable for dance-driven artists like Madonna, Janet Jackson and Britney Spears, whose emphasis on intense, intricate choreography makes it hard to execute the moves fans have come to expect while also singing live. Huffing and puffing into the microphone or barely projecting for the sake of keeping it real just isn't gonna cut it. Of course, there have been other instances – such as Ashlee Simpson's 2004 Saturday Night Live debacle – where faking it crossed the line.

Surely there wouldn't be the same controversy about Beyoncé had she been hoofing across the stage performing "Single Ladies (Put a Ring on It)" on one of her tour stops. But this was the presidential inauguration, the national anthem, and there was no choreography involved.

Some things have to remain sacred, and for "the land of the free and the home of the brave," this was one of them.

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Flu season fuels debate over paid sick time laws

NEW YORK (AP) — Sniffling, groggy and afraid she had caught the flu, Diana Zavala dragged herself in to work anyway for a day she felt she couldn't afford to miss.

A school speech therapist who works as an independent contractor, she doesn't have paid sick days. So the mother of two reported to work and hoped for the best — and was aching, shivering and coughing by the end of the day. She stayed home the next day, then loaded up on medicine and returned to work.

"It's a balancing act" between physical health and financial well-being, she said.

An unusually early and vigorous flu season is drawing attention to a cause that has scored victories but also hit roadblocks in recent years: mandatory paid sick leave for a third of civilian workers — more than 40 million people — who don't have it.

Supporters and opponents are particularly watching New York City, where lawmakers are weighing a sick leave proposal amid a competitive mayoral race.

Pointing to a flu outbreak that the governor has called a public health emergency, dozens of doctors, nurses, lawmakers and activists — some in surgical masks — rallied Friday on the City Hall steps to call for passage of the measure, which has awaited a City Council vote for nearly three years. Two likely mayoral contenders have also pressed the point.

The flu spike is making people more aware of the argument for sick pay, said Ellen Bravo, executive director of Family Values at Work, which promotes paid sick time initiatives around the country. "There's people who say, 'OK, I get it — you don't want your server coughing on your food,'" she said.

Advocates have cast paid sick time as both a workforce issue akin to parental leave and "living wage" laws, and a public health priority.

But to some business owners, paid sick leave is an impractical and unfair burden for small operations. Critics also say the timing is bad, given the choppy economy and the hardships inflicted by Superstorm Sandy.

Michael Sinensky, an owner of seven bars and restaurants around the city, was against the sick time proposal before Sandy. And after the storm shut down four of his restaurants for days or weeks, costing hundreds of thousands of dollars that his insurers have yet to pay, "we're in survival mode."

"We're at the point, right now, where we cannot afford additional social initiatives," said Sinensky, whose roughly 500 employees switch shifts if they can't work, an arrangement that some restaurateurs say benefits workers because paid sick time wouldn't include tips.

Employees without sick days are more likely to go to work with a contagious illness, send an ill child to school or day care and use hospital emergency rooms for care, according to a 2010 survey by the University of Chicago's National Opinion Research Center. A 2011 study in the American Journal of Public Health estimated that a lack of sick time helped spread 5 million cases of flu-like illness during the 2009 swine flu outbreak.

To be sure, many employees entitled to sick time go to work ill anyway, out of dedication or at least a desire to project it. But the work-through-it ethic is shifting somewhat amid growing awareness about spreading sickness.

"Right now, where companies' incentives lie is butting right up against this concern over people coming into the workplace, infecting others and bringing productivity of a whole company down," said John A. Challenger, CEO of employer consulting firm Challenger, Gray & Christmas.

Paid sick day requirements are often popular in polls, but only four places have them: San Francisco, Seattle, Washington, D.C., and the state of Connecticut. The specific provisions vary.

Milwaukee voters approved a sick time requirement in 2008, but the state Legislature passed a law blocking it. Philadelphia's mayor vetoed a sick leave measure in 2011; lawmakers have since instituted a sick time requirement for businesses with city contracts. Voters rejected a paid sick day measure in Denver in 2011.

In New York, City Councilwoman Gale Brewer's proposal would require up to five paid sick days a year at businesses with at least five employees. It wouldn't include independent contractors, such as Zavala, who supports the idea nonetheless.

The idea boasts such supporters as feminist Gloria Steinem and "Sex and the City" actress Cynthia Nixon, as well as a majority of City Council members and a coalition of unions, women's groups and public health advocates. But it also faces influential opponents, including business groups, Mayor Michael Bloomberg and City Council Speaker Christine Quinn, who has virtually complete control over what matters come to a vote.

Quinn, who is expected to run for mayor, said she considers paid sick leave a worthy goal but doesn't think it would be wise to implement it in a sluggish economy. Two of her likely opponents, Public Advocate Bill de Blasio and Comptroller John Liu, have reiterated calls for paid sick leave in light of the flu season.

While the debate plays out, Emilio Palaguachi is recovering from the flu and looking for a job. The father of four was abruptly fired without explanation earlier this month from his job at a deli after taking a day off to go to a doctor, he said. His former employer couldn't be reached by telephone.

"I needed work," Palaguachi said after Friday's City Hall rally, but "I needed to see the doctor because I'm sick."

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Associated Press writer Susan Haigh in Hartford, Conn., contributed to this report.

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Follow Jennifer Peltz at http://twitter.com/jennpeltz

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Banks, commodity stocks lift S&P 500 to five-year high

NEW YORK (Reuters) - Bank and commodity shares led the benchmark Standard & Poor's 500 Index to a fresh five-year closing high on Tuesday on hopes that the global economy continues to mend.

Travelers' shares climbed after the insurer's results and lifted the Dow Jones industrial average to a new five-year closing high.

On Friday, both the Dow and the S&P 500 ended at five-year highs after the quarterly earnings season got off to a solid start. On Monday, the U.S. stock market was closed in observance of the Martin Luther King, Jr., holiday.

In Tuesday's session, the market also gained on signals that Republican leaders in the U.S. House of Representatives aim on Wednesday to pass a bill to extend the U.S. debt limit by nearly four months to May 19. The White House welcomed the move, saying it would remove uncertainty about the issue.

Investors, however, were cautious ahead of an increase in earnings reports and as the S&P 500 rose for a fifth straight session.

Jack de Gan, chief investment officer of Harbor Advisory Corp, in Portsmouth, New Hampshire, said better economic numbers in the United States and China, as well as more stabilization in Europe, were driving buyers into sectors associated with economic growth.

"Any (bearish) news could turn us down for a day or so," he said, referring to the recent string of gains.

Freeport-McMoRan Copper & Gold led gains in the materials sector after it reported a 16 percent rise in fourth-quarter profit on higher production. Shares gained 4.6 percent to $35.19.

The Dow Jones industrial average <.dji> rose 62.51 points, or 0.46 percent, to 13,712.21 at the close. The S&P 500 <.spx> gained 6.58 points, or 0.44 percent, to 1,492.56. The Nasdaq Composite <.ixic> added 8.47 points or 0.27 percent, to 3,143.18.

Tuesday's session marked the highest closes for both the Dow and the S&P 500 since December 2007.

Technology shares underperformed as concerns about Apple's ability to continue to grow at hyper speed and a weak outlook from Intel Corp diminished optimism about the sector's prospects. The S&P technology index <.splrct> added 0.16 percent for the day. In comparison, the S&P energy sector index <.spny>, the S&P financials index <.spsy> and the S&P basic materials index <.splrcm> each gained 0.9 percent.

But Google shares rose 4.8 percent to above $736 in extended-hours trading after the world's No. 1 search engine reported a jump in fourth-quarter revenue. Shares of IBM added more than 4 percent to trade above $204 after the world's largest technology services company reported earnings and revenue that beat estimates.

"We expected Q4 for many tech vendors would be weak because we were expecting a lot of companies sitting on their wallets until it became clear what was going to become of the fiscal cliff," Forrester analyst Andrew Bartels said about IBM.

"Given the fact it's Q4 and the cloud of fiscal cliff within it, it's a positive indication that especially tech software will be doing better in the next couple of months."

During the regular session, shares of blue chips Travelers, DuPont

, and Verizon Communications rose following earnings.

Travelers rose 2.2 percent to $77.95, a closing high. DuPont's shares gained 1.8 percent to $47.82. Verizon's stock rose 0.9 percent to $42.94.

Thomson Reuters data through Tuesday morning showed that of the 74 S&P 500 companies that have reported earnings so far, 62.2 percent have topped expectations, roughly even with the 62 percent average since 1994, but below the 65 percent average over the past four quarters.

Overall, S&P 500 fourth-quarter earnings are forecast to have risen 2.6 percent. That estimate is above the 1.9 percent forecast from the start of earnings season, but well below the 9.9 percent fourth-quarter earnings forecast from October 1, the data showed.

U.S.-listed shares of Research in Motion rallied 13 percent to $17.90 a day after its chief executive said the Canadian company may consider strategic alliances with other companies after the launch of devices powered by RIM's new BlackBerry 10 operating system.

About 6.2 billion shares changed hands on the New York Stock Exchange, the Nasdaq and NYSE MKT, below last year's daily average of about 6.45 billion shares.

On the NYSE, advancers outnumbered decliners by a ratio of roughly 9 to 4. On the Nasdaq, five stocks rose for every three that fell.

Signs of improved sentiment toward world growth were also seen in European bond markets. The yield on Portugal's benchmark 10-year note fell below 6 percent for the first time since late 2010 on news that the country was set to tap the bond market this week for the first time since it was bailed out in 2011.

(Reporting by Rodrigo Campos; Additional reporting by Jennifer Saba; Editing by Jan Paschal)

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