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The New EnglandJournal of Medicine©Copyright, 1996, by the Massachusetts Medical Societ yTHE EFFECT OF PRAVASTATIN ON CORONARY EVENTSAFTER MYOCARDIAL INFARCTION IN PATIENTSWITH AVERAGE CHOLESTEROL LEVELSF RANK M. S ACKS , M.D., M ARC A. P FEFFER , M.D., P H .D., L EMUEL A. M OYE , M.D., P H .D., J EAN L. R OULEAU , M.D.,J OHN D. R UTHERFORD , M.D., T HOMAS G. C OLE , P H .D., L ISA B ROWN , M.P.H., J. W AYNE W ARNICA , M.D.,J. M ALCOLM O. A RNOLD , M.D., C HUAN -C HUAN W UN , P H .D., B ARRY R. D AVIS , M.D., P H .D.,AND E UGENE B RAUNWALD , M.D., FOR THE C HOLESTEROL AND R ECURRENT E VENTS T RIAL I NVESTIGATORS *ABSTRACTBackground In patients with high cholesterol lev-els, lowering the cholesterol level reduces the risk of coronary events, but the effect of lowering cholester-ol levels in the majority of patients with coronary disease, who have average levels, is less clear.Methods In a double-blind trial lasting five years,we administered either 40 mg of pravastatin per day or placebo to 4159 patients (3583 men and 576 wom-en) with myocardial infarction who had plasma total cholesterol levels below 240 mg per deciliter (mean,209) and low-density lipoprotein (LDL) cholesterol levels of 115 to 174 mg per deciliter (mean, 139). The primary end point was a fatal coronary event or a nonfatal myocardial infarction.Results The frequency of the primary end point was 10.2 percent in the pravastatin group and 13.2percent in the placebo group, an absolute difference of 3 percentage points and a 24 percent reduction in risk (95 percent confidence interval, 9 to 36 percent;P ϭ 0.003). Coronary bypass surgery was needed in 7.5 percent of the patients in the pravastatin group and 10 percent of those in the placebo group, a 26percent reduction (P ϭ 0.005), and coronary angio-plasty was needed in 8.3 percent of the pravastatin group and 10.5 percent of the placebo group, a 23percent reduction (P ϭ 0.01). The frequency of stroke was reduced by 31 percent (P ϭ 0.03). There were no significant differences in overall mortality or mortal-ity from noncardiovascular causes. Pravastatin low-ered the rate of coronary events more among wom-en than among men. The reduction in coronary events was also greater in patients with higher pretreat-ment levels of LDL cholesterol.Conclusions These results demonstrate that the benefit of cholesterol-lowering therapy extends to the majority of patients with coronary disease who have average cholesterol levels. (N Engl J Med 1996;335:1001-9.)©1996, Massachusetts Medical Society.From the Departments of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston (F.M.S., M.A.P ., L.B., E.B.); the Univer-sity of T exas School of Public Health, Houston (L.A.M., C.-C.W., B.R.D.);the University of Sherbrooke, Sherbrooke, Que., Canada (J.L.R.); the Uni-versity of T exas Southwestern Medical Center, Dallas (J.D.R.); Washington University, St. Louis (T .G.C.); Foothills Hospital, Calgary, Alta., Canada (J.W.W.); and Victoria Hospital, London, Ont., Canada (J.M.O.A.). Address reprint requests to Dr. Sacks at Brigham and Women’s Hospital, 75 Francis St., Boston, MA 02115.Other contributing authors were Pierre Theroux, M.D., Montreal Heart Institute, Montreal; David T . Nash, M.D., State University of New Y ork Health Sciences Center, Syracuse; and C. Morton Hawkins, D.Sc., Univer-sity of T exas School of Public Health, Houston.*Participants in the Cholesterol and Recurrent Events trial are listed in the Appendix.HE plasma levels of total cholesterol and low-density lipoprotein (LDL) cholesterol are important risk factors for coronary heart disease. 1-4 However, the relation betweenplasma cholesterol and coronary events appears to be stronger if levels are at elevated, rather than average,values. 1-4 Angiography in clinical trials has demon-strated that lowering cholesterol levels slows the pro-gression and promotes the regression of coronary ath-erosclerosis. 5 These beneficial changes are also directly related to the pretreatment level of LDL cholester-ol, 5,6 with little benefit occurring in patients with av-erage base-line levels. 7 Clinical trials have shown that lowering elevated LDL cholesterol levels prevents both first and recurrent coronary events. 8-11 However,it has not been clear whether coronary events can be prevented by cholesterol-lowering therapy in patients who do not have hypercholesterolemia. This issue is of importance because the large majority of patients with coronary disease have cholesterol levels that are,like those of the general population, 12 in the average,not the elevated, range.13-16The Cholesterol and Recurrent Events (CARE)Ttrial and its entry criteria (a plasma total cholesterol level of less than 240 mg per deciliter [6.2 mmol per liter] and an LDL cholesterol level of 115 to 174 mg per deciliter [3.0 to 4.5 mmol per liter]) were de-signed specifically to study the effectiveness in a typ-ical population of lowering LDL cholesterol levels to prevent coronary events after myocardial infarction.METHODSStudy Design and PatientsThe design of the CARE trial has been described in detail else-where. 17 Patients were recruited from 80 participating centers, 13in Canada and 67 in the United States. Men and postmenopausal women were eligible if they had had an acute myocardial infarction between 3 and 20 months before randomization, were 21 to 75years of age, and had plasma total cholesterol levels of less than 240mg per deciliter, LDL cholesterol levels of 115 to 174 mg per dec-iliter, fasting triglyceride levels of less than 350 mg per deciliter (4.0mmol per liter), fasting glucose levels of no more than 220 mg per deciliter (12.2 mmol per liter), left ventricular ejection fractions of no less than 25 percent, and no symptomatic congestive heart fail-ure. Criteria for a qualifying myocardial infarction included typical symptoms and an elevated serum level of creatine kinase. 17 The lip-id levels, as measured at two or three specified visits to the clinic at least eight weeks after hospitalization for myocardial infarction and after four weeks of treatment with the National Cholesterol Edu-cation Program (NCEP) Step 1 diet, 18 were averaged for eligibility.After stratification according to clinical center, we randomly as-signed the eligible patients to receive either 40 mg of pravastatin (Pravachol, Bristol-Myers Squibb) once daily, or a matching place-bo, by means of a telephone call to the data center. After random-ization, visits to the clinic took place quarterly. Patients continued to take all prescribed medication, for cardiac and other conditions,that they had been receiving at base line (Table 1).Plasma total cholesterol, high-density lipoprotein (HDL) cho-lesterol, and triglyceride levels were measured by the core labora-tory at base line, at 6 and 12 weeks after randomization, at the end of each quarter during the first year, and semiannually there-after. LDL cholesterol levels were calculated. 19 For any patient in either group with an LDL cholesterol level of 175 mg per deci-liter (4.5 mmol per liter) or more, intensified (NCEP Step 2) di-etary counseling was initiated. 18 If the LDL level remained at 175mg per deciliter or more, cholestyramine was prescribed, in a daily dose of 8 to 16 g, as needed, to decrease the level to less than 175 mg per deciliter. T o maintain blinded conditions, a pa-tient in the other treatment group who was matched for age and sex and had an LDL cholesterol level in the highest decile was provided with parallel dietary counseling and cholestyramine treatment. If counseling and treatment were unsuccessful, the pa-tient with a persistently elevated LDL cholesterol level was re-ferred to his or her physician for treatment. The primary end point of the trial was death from coronary heart disease (includ-ing fatal myocardial infarction, either definite or probable; sud-den death; death during a coronary intervention; and death from other coronary causes) or a symptomatic (unless during noncar-diac surgery) nonfatal myocardial infarction confirmed by serum creatine kinase measurements. In each group, we measured the time elapsed to the primary end point. Deaths were reviewed by the end-points committee without knowledge of the patient’s treatment assignment or plasma lipid levels.The protocol was approved by the Safety and Data Monitoring Committee and the institutional review boards of all participating centers.Statistical AnalysisThe size of the sample was designed to provide an 80 percent power to detect a 20 percent reduction in the number of primary*Plus–minus values are means Ϯ SD. Except for the use of oral hypoglycemic agents, differences between the groups were not significant. CABG denotes coronary-artery bypass grafting, PTCA percutaneous transluminal coronary angio-plasty, ACE angiotensin-converting enzyme, VLDL very-low-density lipoprotein, LDL low-density lipoprotein, and HDL high-density lipoprotein.†The body-mass index is the weight in kilograms divided by the square of the height in meters.‡P Ͻ 0.05 for the comparison with the placebo group.§T o convert values for cholesterol to millimoles per liter,multiply by 0.02586. T o convert values for triglycerides to millimoles per liter, multiply by 0.01129.T ABLE 1. B ASE -L INE C HARACTERISTICS OF P ATIENTS IN THE P LACEBO AND P RAVASTATIN G ROUPS .*C HARACTERISTICP LACEBO (N ؍ 2078)P RAVASTATIN (N ؍ 2081)General Age (yr)59 Ϯ 959 Ϯ 9Sex (%)Female Male 14861486Race (%)White Other928937Country of residence (%)United States Canada66346634Hypertension (%)4342Current smoker (%)2121Diabetes (%)1514Body-mass index†28 Ϯ 428 Ϯ 4Blood pressure (mm Hg)Systolic Diastolic129 Ϯ 1879 Ϯ 10129 Ϯ 1879 Ϯ 10 Cardiovascular statusMonths from myocardial infarctionto randomization10 Ϯ 510 Ϯ 5Type of myocardial infarction (%)Q wave Other 61386138Angina (%)2021Congestive heart failure (%)44CABG (%)2826PTCA (%)3234CABG or PTCA (%)5454Thrombolysis (%)4042Ejection fraction (%)53 Ϯ 1253 Ϯ 12 Medication use Aspirin (%)8383Beta-blocker (%)3941Nitrate (%)3332Calcium-channel blocker (%)3840ACE inhibitor (%)1415Diuretic agent (%)1111Insulin (%)2.6 2.4Oral hypoglycemic agent (%)75‡Estrogen (% of women)10.38.4Plasma lipids §Cholesterol (mg/dl)T otal VLDL LDL HDL209 Ϯ 1727 Ϯ 16139 Ϯ 1539 Ϯ 9209 Ϯ 1727 Ϯ 16139 Ϯ 1539 Ϯ 9Triglycerides (mg/dl)155 Ϯ 61156 Ϯ61events with pravastatin. All analyses were performed on an inten-tion-to-treat basis, and P values were two-sided. The effect of therapy on the rate of the primary end point of the trial was as-sessed with use of log-rank P values. 20 All other hypothesis tests and all reductions in risk were assessed with a Cox proportional-hazards model. 21 The size of the trial did not provide adequate power to assess therapeutic efficacy against the primary end point within subgroups. Therefore, treatment effects were analyzed in several prespecified subgroups with a more broadly defined end point: major coronary events (including fatal coronary heart dis-ease, nonfatal myocardial infarction, bypass surgery, and angio-plasty).RESULTSBetween December 4, 1989, and December 31,1991, 4159 patients were randomly assigned to study groups, 2078 to the placebo group and 2081 to the pravastatin group. The characteristics of the patients before randomization were similar in the two groups (Table 1). In the last year of follow-up, 86 percent of the placebo group and 94 percent of the treat-ment group were taking their study medication.This included the 6 percent of patients in each treat-ment group who were taking cholestyramine ac-cording to the protocol. Of the patients, 8 percent in the placebo group and 2 percent in the treatment group discontinued the study medication and start-ed treatment to lower lipid levels with open-label drug therapy, as prescribed by their personal physi-cians. The final study visit was between January 1and February 14, 1996, at which time the median duration of follow-up was 5.0 years (range, 4.0 to 6.2). Data were obtained to classify myocardial in-farctions as confirmed or unconfirmed for all pa-tients in whom a myocardial infarction was report-ed. Vital status was ascertained for the first four years for all patients and, at the end, for all but one patient.Pravastatin therapy lowered the mean LDL cho-lesterol level of 139 mg per deciliter (3.6 mmol per liter) by 32 percent and maintained mean levels of 97 to 98 mg per deciliter (2.5 mmol per liter)throughout the five-year follow-up. During follow-up, the LDL cholesterol level was 28 percent lower in the pravastatin group than in the placebo group,the total cholesterol level was 20 percent lower, the HDL cholesterol level was 5 percent higher, and the triglyceride level was 14 percent lower (P Ͻ 0.001 for all comparisons).Patients treated with pravastatin had a 24 percent lower incidence of the primary end point, fatal cor-onary heart disease or confirmed myocardial infarc-tion, than patients in the placebo group (95 percent confidence interval, 9 to 36 percent; P ϭ 0.003) (Ta-ble 2 and Fig. 1). Two hundred seventy-four pa-tients (13.2 percent) had a primary event in the pla-cebo group, as compared with 212 (10.2 percent) in the pravastatin group. One hundred seventy-three*Risk reductions and P values were based on Cox proportional-hazards analysis; P values are iden-tical to those derived by log-rank analysis. Patient-specific data were used to compute P values andconfidence intervals (CI). CHD denotes coronary heart disease, MI myocardial infarction, CABG coronary-artery bypass grafting, and PTCA percutaneous transluminal coronary angioplasty.†This combined variable was the specified primary end point. Nonfatal myocardial infarctions were confirmed by the core laboratory.‡This variable comprises all nonfatal myocardial infarctions reported by investigators.T ABLE 2. C ARDIOVASCULAR E VENTS A CCORDING TO S TUDY G ROUP .*E VENTP LACEBO (N ؍2078)P RAVASTATIN (N ؍2081)R ISK R EDUCTIONWITH P RAVASTATIN(95% CI)P V ALUENO . OF PATIENTSINCIDENCE(%)NO . OF PATIENTSINCIDENCE(%)percentDeath from CHD or non-fatal MI†27413.221210.224 (9 to 36)0.003Death from CHD 119 5.796 4.620 (Ϫ5 to 39)0.10Nonfatal MI 1738.3135 6.523 (4 to 39)0.02Fatal MI38 1.824 1.237 (Ϫ5 to 62)0.07Fatal MI or confirmed non-fatal MI20710.01577.525 (8 to 39)0.006Clinical nonfatal MI‡23111.11828.723 (6 to 36)0.01CABG 20710.01567.526 (8 to 40)0.005PTCA21910.51728.323 (6 to 37)0.01CABG or PTCA 39118.829414.127 (15 to 37)Ͻ0.001Unstable angina 35917.331715.213 (Ϫ1 to 25)0.07Stroke783.8542.631 (3 to 52)0.03Figure 1. Kaplan–Meier Estimates of the Incidence of Coronary Events in the Pravastatin and Placebo Groups.15105012345I n c i d e n c e (%)0252015105012345I n c i d e n c e (%)N O. AT R ISK Placebo Pravastatin2078208120092015195619631881191518101856854900N O. AT R ISK Placebo Pravastatin2078208119561969185718771739180016341716754819PlaceboPravastatinChange in risk,Ϫ27%P Ͻ0.001Change in risk,Ϫ24%P ϭ0.003PlaceboPravastatinFatal Coronary Heart Disease or Nonfatal Myocardial InfarctionCoronary Bypass Surgery or AngioplastyYearsYears*Major coronary events were the primary end point (death from coronary heart disease or nonfatalmyocardial infarction [MI]), coronary-artery bypass grafting (CABG), or percutaneous transluminal coronary angioplasty (PTCA). P values for the interaction between subgroup and treatment were Ͼ0.10 except for sex (P ϭ0.05), LDL cholesterol level (Ͻ125, 125–150, and Ͼ150 mg per deciliter;P ϭ0.03), and triglyceride level (P ϭ0.08). LDL denotes low-density lipoprotein, and HDL high-density lipoprotein.†The median values for all 4159 patients were as follows: total cholesterol, 209 mg per deciliter;LDL cholesterol, 137 mg per deciliter; HDL cholesterol, 37 mg per deciliter; LDL:HDL ratio, 3.7;and triglycerides, 144 mg per deciliter. T o convert values for cholesterol to millimoles per liter, mul-tiply by 0.02586. T o convert values for triglycerides to millimoles per liter, multiply by 0.01129.‡The type of myocardial infarction could not be determined for three patients.T ABLE 3. M AJOR C ORONARY E VENTS IN S UBGROUPS D EFINED BY B ASE -L INE V ARIABLES .*V ARIABLE †N O . OF P ATIENTSN O . (%) OF P ATIENTSWITH E VENTR ISK R EDUCTION (95% CI)P V ALUEPLACEBOPRAVASTATINPLACEBOPRAVASTATINpercentSexFemale Male 2901788286179580 (28)469 (26)46 (16)384 (21)46 (22 to 62)20 (8 to 30)0.0010.001AgeϽ60 yr у60 yr 1003107510271054258 (26)291 (27)217 (21)213 (20)20 (4 to 33)27 (12 to 38)0.02Ͻ0.001Hypertension Present Absent 89911798751206263 (29)286 (24)200 (23)230 (19)23 (8 to 36)24 (9 to 36)0.0050.002Diabetes Present Absent 30417742821799112 (37)437 (25)81 (29)349 (19)25 (0 to 43)23 (11 to 33)0.05Ͻ0.001Smoking Current Other33417443371744111 (33)437 (25)81 (24)349 (20)33 (11 to 50)22 (10 to 33)0.006Ͻ0.001Left ventricular ejec-tion fraction р40%Ͼ40%35317253531728112 (32)436 (25)84 (24)346 (20)28 (4 to 45)23 (11 to 33)0.02Ͻ0.001Previous CABG Yes No56415145271554116 (21)433 (29)88 (17)342 (22)22 (Ϫ3 to 41)25 (13 to 35)0.08Ͻ0.001Previous PTCA Yes No66814107011380188 (28)361 (26)153 (22)277 (20)25 (7 to 39)23 (10 to 34)0.009Ͻ0.001Previous CABG orPTCA Yes No11189601127954269 (24)280 (29)218 (19)212 (22)22 (7 to 35)25 (10 to 37)0.0060.002Type of MI‡Q wave Other12777991279801334 (26)215 (27)251 (20)179 (22)27 (14 to 38)19 (1 to 34)Ͻ0.0010.04T otal cholesterol р209 mg/dl Ͼ209 mg/dl 1040103810321049260 (25)289 (28)211 (20)219 (21)19 (3 to 33)27 (13 to 39)0.02Ͻ0.001LDL cholesterol р137 mg/dl Ͼ137 mg/dl 1048103010421039269 (26)280 (27)210 (20)220 (21)23 (8 to 36)24 (10 to 36)0.0040.002LDL cholesterol Ͻ125 mg/dl 125–150 mg/dl Ͼ150–175 mg/dl 4411172465410118348893 (21)311 (27)145 (31)89 (22)239 (20)102 (21)Ϫ3 (Ϫ38 to 23)26 (13 to 38)35 (17 to 50)0.85Ͻ0.0010.008HDL cholesterol р37 mg/dl Ͼ37 mg/dl 1025105310331048290 (28)259 (25)236 (23)194 (19)21 (6 to 33)27 (12 to 39)0.008Ͻ0.001LDL:HDL ratio Ͻ3.7у3.71043103510361045251 (24)298 (29)190 (18)240 (23)26 (11 to 39)21 (7 to 34)0.0020.006Triglycerides Ͻ144 mg/dl у144 mg/dl1049102910311050281 (27)268 (26)195 (19)235 (22)32 (18 to 43)15 (Ϫ1 to 29)Ͻ0.0010.0703530252015105012345I n c i d e n c e (%)N O. AT R ISK Placebo 441410411384396363378343354322153160117211831089110610221055 9511010891963426443465488434451410426375407344387144189PravastatinChange in risk,ϩ3%P ϭ0.85Pravastatin Placebo03530252015105012345Change in risk,Ϫ26%P Ͻ0.001PravastatinPlacebo0353*******105012345PravastatinPlaceboLDL, Ͻ125 mg/dlLDL, 125 –150 mg/dlLDL, Ͼ150 mg/dlYearsYearsYearsChange in risk,Ϫ35%P ϭ0.008with impaired left ventricular ejection, in all of whom the efficacy of lowering cholesterol levels had been questioned, had a reduction in risk. These re-sults demonstrate that for patients with coronary disease in North America, the average cholesterol level is too high and can contribute to the recur-rence of cardiovascular events.These results also suggest that the pretreatment LDL cholesterol level, at least within the CARE tri-al’s eligibility range of 115 to 174 mg per deciliter, has an influence on the success of cholesterol-lower-ing therapy in preventing coronary events. In the upper part of the range, Ͼ150 to 175 mg per deci-liter, the reduction in risk (35 percent) was similar to that achieved with reductase inhibitors in patients with hypercholesterolemia.8-10 In the middle of the range, 125 to 150 mg per deciliter, the risk reduc-tion remained substantial (26 percent); this range is at the center of the distribution of LDL cholesterol values in contemporary populations with coronary heart disease.13-16However, there was no reduction in coronary events among patients with base-line LDL cholesterol levels below 125 mg per deciliter. These results are consistent with those of epidemio-logic studies that show a stronger relation between LDL cholesterol levels and coronary events at hyper-cholesterolemic, as compared with average, levels,1-4 as well as those of angiographic studies that show that improvement in coronary-artery stenosis in pa-tients receiving lipid-lowering therapy is proportion-al to the base-line LDL cholesterol level.5-7 Although our finding cannot be considered definitive and re-quires confirmation, it suggests that an LDL choles-terol level of 125 mg per deciliter may be an approx-imate lower boundary for a clinically important influence of the LDL cholesterol level on coronary heart disease.Stroke, a specified end point in the CARE trial,17 was reduced significantly (by 31 percent) in the pra-vastatin group. A reduction in cerebrovascular end points was found in post hoc analyses of data from several previous trials conducted in hypercholester-olemic populations.8,10,22,23A meta-analysis of trials of pravastatin in patients with atherosclerosis showed a significant, 62 percent reduction in stroke.10 Die-tary therapy that replaced saturated fat with polyun-saturated fat reduced the incidence of stroke by 45 percent (Pϭ0.055).22The incidence of stroke and transient ischemic attacks considered together was lowered significantly (by 24 percent) by nicotinic acid23and lowered by 30 percent by simvastatin.8 Ultrasound measurements of carotid atherosclerosis demonstrated slowing of the progression of disease by treatment with pravastatin24,25and lovastatin.26 This evidence from clinical trials therefore suggests that high plasma LDL cholesterol levels are a treat-able cause of cerebrovascular atherosclerosis and clin-ical cerebrovascular events. The potential for benefit from cholesterol-lowering treatment should contin-ue to be evaluated in patients with coronary disease, as well as in other groups of patients at high risk for stroke, such as those with a history of stroke, tran-sient ischemic attack, carotid-artery bruit, or hyper-tension.The overall incidence of fatal or nonfatal cancer was not increased in the pravastatin group as com-pared with the placebo group. The incidence of gas-trointestinal, liver, and lymphatic cancers was also not increased, thus providing no confirmation in humans of findings from testing in animals.27The increased incidence of breast cancer in patients given pravastatin was surprising; it has not been reported in previous or ongoing trials with pravastatin or oth-er related drugs, and testing in animals has not iden-tified breast cancer as one that is increased by such therapy. There is also no known potential biologic basis, such as an increase in estrogen levels,28 to sug-gest a causal link. In evaluating this finding, it should be noted that although there was one case of breast cancer among the women given placebo, five cases would have been expected on the basis of the rate of breast cancer in the general population for women of similar race and age.29 Importantly, interim results of the Long-T erm Intervention with Pravastatin in Ischemic Disease (LIPID) trial,30 from four years of treatment of 1508 women, show no increase in breast cancer (Barter P, Safety and Data Monitoring Committee, LIPID study: personal communication). The totality of evidence suggests that these findings in the CARE trial could be an anomaly and may be best interpreted in the context of the trial’s very low event rates and statistical testing of many adverse events.The Scandinavian Simvastatin Survival Study was a study of secondary prevention in patients with hy-percholesterolemia and coronary disease in which the reduction in coronary events was 37 percent.8 In the 544 CARE patients who, on the basis of lipid levels and other characteristics, would have been el-igible for the Scandinavian study, the reduction in coronary events (as defined in that study) was 43 percent in the pravastatin group as compared with the placebo group (Pϭ0.048). Therefore, we con-clude that the difference in overall risk reduction in the two trials was caused mainly by the difference in the base-line LDL cholesterol levels of the two groups of subjects, although other characteristics, such as a greater use of aspirin by the CARE patients, may also have contributed. The results of the CARE trial should be considered representative of what can be achieved by lipid-lowering treatment, over and above other strategies currently employed in the modern, comprehensive treatment of patients with a history of myocardial infarction and average choles-terol levels.We calculated the overall clinical benefit that couldcular disease in relation to cholesterol level among men with and without preexisting cardiovascular disease. N Engl J Med 1990;322:1700-7.4.Kannel WB. Range of serum cholesterol values in the population devel-oping coronary artery disease. Am J Cardiol 1995;76:69C-77C.5.Rossouw JE. Lipid-lowering interventions in angiographic trials. 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Reduction in cardiovascu-lar events during pravastatin therapy: pooled analysis of clinical events of the Pravastatin Atherosclerosis Intervention Program. Circulation 1995; 92:2419-25.11.Holme I. Cholesterol reduction and its impact on coronary artery dis-ease and total mortality. Am J Cardiol 1995;76:10C-17C.12.Johnson CL, Rifkind BM, Sempos CT, et al. Declining serum total cholesterol levels among US adults: the National Health and Nutrition Ex-amination Surveys. JAMA 1993;269:3002-8.vie CJ, Milani RV. National Cholesterol Education Program’s rec-ommendations and implications of “missing” high-density lipoprotein cho-lesterol in cardiac rehabilitation programs. Am J Cardiol 1991;68:1087-8.14.Buring JE, O’Connor GT, Goldhaber SZ, et al. Decreased HDL2 and HDL3 cholesterol, Apo A-I and Apo A-II, and increased risk of myocardial infarction. Circulation 1992;85:22-9.15.Genest J Jr, McNamara JR, Ordovas JM, et al. 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Estimation of the concen-tration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem 1972;18:499-502.20.Kalbfleisch JD, Prentice RL. The statistical analysis of failure time da-ta. New Y ork: John Wiley, 1980.21.Cox DR. Regression models and life-tables. J R Stat Soc [B] 1972;34: 187-220.22.Dayton S, Pearce ML, Hashimoto S, Dixon WJ, T omiyasu U. A con-trolled clinical trial of a diet high in unsaturated fat in preventing compli-cations of atherosclerosis. Circulation 1969;40:Suppl II:II-1–II-63.23.The Coronary Drug Project Research Group. Clofibrate and niacin in coronary heart disease. JAMA 1975;231:360-81.24.Crouse JR III, Byington RP, Bond MG, et al. Pravastatin, Lipids, and Atherosclerosis in the Carotid Arteries (PLAC-II). Am J Cardiol 1995;75: 455-9. [Erratum, Am J Cardiol 1995;75:862.]25.Salonen R, Nyyssonen K, Porkkala E, et al. Kuopio Atherosclerosis Prevention Study (KAPS): a population-based primary prevention trial of the effect of LDL lowering on atherosclerotic progression in carotid and femoral arteries. Circulation 1995;92:1758-64.26.Furberg CD, Adams HP Jr, Applegate WB, et al. Effect of lovastatin on early carotid atherosclerosis and cardiovascular events. Circulation 1994;90:1679-87.27.Newman TB, Hulley SB. Carcinogenicity of lipid-lowering drugs. JAMA 1996;275:55-60.28.Dobs AS, Sarma PS, Schteingart D. Long-term endocrine function in hypercholesterolemic patients treated with pravastatin, a new 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitor. Metabolism 1993;42: 1146-52.29.Ries LA, Miller BA, Hankey BF, Kosary CL, Haras A, Edwards BK, eds. SEER cancer statistics review, 1973-1991: tables and graphs. Bethes-da, Md.: National Cancer Institute, 1994. (NIH publication no. 94-2789.)30.The Lipid Study Group. Design features and baseline characteristics of the LIPID (Long-T erm Intervention with Pravastatin in Ischemic Disease) Study: a randomized trial in patients with previous acute myocardial infarc-tion and/or unstable angina pectoris. Am J Cardiol 1995;76:474-9. 31.Pfeffer MA, Sacks FM, Moye LA, et al. Cholesterol and Recurrent Events [CARE]: a secondary prevention trial for normolipidemic patients. Am J Cardiol 1995;76:98C-106C.MASSACHUSETTS MEDICAL SOCIETY REGISTRY ON CONTINUING MEDICAL EDUCATION T o obtain information about continuing medical education courses in New England, callbetween 9 a.m. and 12 noon, Monday through Friday, (617) 893-4610, or in Massachusetts, 1-800-322-2303, ext. 1342.。

Unit 5I. Blank-filling1. The nickname for the USA national flag is “_____Old Glory________________”.2. The state of ____Virginia______ was named in honor of Queen Elizabeth I.3. As US national motto, “E Pluribus Unum” means _____out of many,one__________5. As pen name of Samuel Langhorne Clemens, Mark Twain means ___Mark number two_______.6. The largest state in terms of area is ___Alaska_______ and the largest state in terms of population is _____California_____.7. The meaning of Mississippi is “_____Father of Waters___”.8. Some ____Puritans_______, called the Pilgrims, crossed the Atlantic in the ship Mayflower andsettled at Plymouth, Massachusetts in 1620.9. The writer O. Henry called ____Thanksgiving Day _______ the one holiday that is purelyAmerican.10. The first shot in the American War of Independence was heard at the village of______Lexington_____ on April 19, 1775.11. In May, 1775, ______the 2th Continental Congress______ met in Philadelphia and began toassume the functions of a national government.12. On June 14, 1776, the second Continental Congress officially appointed __GeorgrWashington___ as commander-in-chief of the Continental Army.13. ___Thomas_Jefferson_ was instructed by the Committee of Five to write the Declaration ofIndependence.14. The Independence Day of the United States is on _____July_4th_______.15. On January 1, 1863, President Lincoln issued the ____ Emancipation Proclamation___________, which granted freedom to all slaves in areas still controlled by the Confederacy.16. The famous “that this government of the people, by the people, for the people”was from___the Gettysburg Address_______17. The 2nd Amendment in the Bill of Rights granted the American people the right to keep andbear ____Arms______.18. The most extreme form of Jim Crow violence is ____Lynching______.19. ___Chinked-out_______ is a new musical style created by Lee-Hom Wang, which blendsChinese traditional music with Western hip-hop rhythms.20. ____The Chinese Exclusion Act of 1882______ serves as the first in US history to ban a specific racial group from entering America.II. Multiple-Choice21. Which of the following states is called “the Old Colony State”? BA. PennsylvaniaB. MassachusettsC. DelawareD. Georgia22. The term “Father of Waters” is used to refer to __________. CA. the Amazon River C. the Mississippi RiverB. the Nile River D. the Hudson River23. Which of the following was not first grown by Native Americans? BA. potato C. pumpkinB. cabbage D. corn24. The first colony at Jamestown in Virginia survived because the colonists discovered a way to earn money. Which of the following was discovered by the Virginians? BA. shipping cotton to EuropeB. growing tobacco in VirginiaC. making a profit by fishingD. growing cotton25. Three of the following were the motives of the English Puritans who went to New England asimmigrants. Which was the exception? AA. They believed that the Church of England was not Catholic enough.B. They believed that the Church of England was too Catholic in religious practices.C. They were persecuted in England.D. They wanted to established a colony based on their own religious ideals.26. Thanksgiving Day is originally celebrated by people for _____. DA. healthB. safetyC. freedomD. harvest27. _____ was the only Founding Father to sign the Declaration of Independence, the UnitedStates Constitution, the Treaty of Alliance with France, and the Treaty of Paris. CA. George WashingtonB. Thomas JeffersonC. Benjamin FranklinD. John Adams28. The following words of wisdom were given by Benjamin Franklin except _____ BA. A penny saved is a penny earned.B. All for one, one for all. ([法] Dumas pére大仲马)C. Time is money.D. Early to bed and early to rise, makes a man healthy, wealthy, and wise.29. George Washington served _____ term(s) as US President. BA. oneB. twoC. threeD. four30. The author of Uncle Tom’s Cabin was ____________. CA. Thomas PaineB. Barbara SmithC. Harriet Beecher StoweD. Mark Twain31.The following people played a great role in Civil Rights Movement except _____. CA. Emmett TillB. Rosa ParksC.Oprah WinfreyD. Martin Luther King, Jr.32. Angel Island was destroyed by _____ in 1940 and was never reopened. CA. an earthquakeB. a thunderstormC.a fireD. a flood33. Which Act removed the last barriers to Chinese immigration initiating a new era in the history of America’s melting pot? CA. The Chinese Exclusion ActB. The Chinese Exclusion Repeal ActC.The Immigration ActD. The Walter-McCarren Act34. Which of the following is not a slur word? AA. blondeB. chinkC.niggerD. round-eyeIII. Question35. What is the significance of the Second Continental Congress? 大陆会议的重要性有3点37. What social problems did the American Civil War solve? 2点38. What are the contributions of the Civil Rights Laws of the 1960s?IV. True or False39. The first English colony was set in Delaware. F40. The bald eagle was chosen as the representative of the United States. T41. Geographically the United States can be roughly divided into three parts—the western part, the southern part and New England. F42. The Appalachian Mountains are the backbone of North America. F43. Fishing and hunting were only a way for American Indians to survive.44. Totem poles were used as the objects of worship.45. Pilgrim Fathers settled at Plymouth in 1607. F46. The purpose of the First Continental Congress was to seek independence from Britain. F47. Benjamin Franklin was the first to celebrate the American Dream. T48. Under the Articles of Confederation, the 13 states were united under a strong centralgovernment.49. US Constitution was signed on September 17, 1787.50. The Bill of Rights ensured the efficient central authority of the federal government. F51. Mount Rushmore is famous for the faces of four American Presidents, who are G. Washington,T. Jefferson, A. Lincoln, and F. Roosevelt. F（Theodore Roosevelt）52. The Battle of Gettysburg was fought on July 1 and 2, 1863 and is considered the turning pointin the Revolutionary War. F(应该是内战Civil War)1. The ancestors of the Welsh are ___a__.A. the CeltsB. the RomansC. the AnglesD. the Normans2. Which of the following is not one of the three Germanic tribes that came to be the basisof modern English race? __a___A. the Viking DanesB. the AnglesC. the SaxonsD. the Jutes3. The historical Arthur is believed by most historians as a __a__ warrior.A. Celtic B Anglo C Saxon D Norman4. For much of the Middle Ages, Britain was ruled by a(n) __b____-speaking aristocracy.A. EnglishB. FrenchC. GermanD. Gaelic5. Normans under William the Conqueror invaded England from France, Defeating theSaxon king Harold at the Battle of ____Hastings_______ in 1066. Hastings6. The full name of the United Kingdom is ____ The United Kingdom of Great Britain___7. The two largest islands of the British Isles are __ Britain __ and _ Ireland ___.8. All the kings of the Middle Ages in Britain spoke ___French__ as their mother tongue,and after the Hundred Years’ War, the __English____ language took its place.9. What are the main consequences of the Norman Conquest?The significance of Norman Conquest lies in the following aspects: The foundation of aristocracy,the final u nification of England ,the great administrative process,and a link to FranceUnit 11 The ancestors of the Welsh are ___A__.A. the CeltsB. the RomansC. the AnglesD. the Normans2 Which of the following is not one of the three Germanic tribes that came to be the basis of modern En glish race? AA. the Viking DanesB. the AnglesC. the SaxonsD. the Jutes3 The historical Arthur is believed by most historians as a _A___ warrior.A. Celtic B Anglo C Saxon D Norman4 For much of the Middle Ages, Britain was ruled by a(n) __B____-speaking aristocracy.A. EnglishB. FrenchC. GermanD. Gaelic5 Normans under William the Conqueror invaded England from France, defeating the Saxon king Harold at the Battle of Hastings in 1066.6 The full name of the United Kingdom is The United Kingdom of Great Britain and Northern Ireland .7 The two largest islands of the British Isles are England and Ireland.8 All the kings of the Middle Ages in Britain spoke French as their mother tongue, and after the Hund red Years’War, the French-English language took its place.9 When the Romans invaded Britain around the year 43 A.D, Britain was a land of B .A. The PictsB. The CeltsC. The Angles10 Which of the following is not one of the three Germanic tribes that came to be the basis of modern English race ? AA. The Viking DanesB. The AnglesC. The Saxons11 In 43 A.D. ,Roman Emperor, C , evaded Britain.A. Julius CaesarB. Augustus CaesarC. Claudius12 Christianity was introduced into Britain by CA. The CeltsB. The GermansC. The Romans13 Who was killed in the Battle of Hastings ? BA. Edward the ConfessorB. Harold GodwinsonC. Harald Hardrade14 For much of the Middle Ages, Britain was ruled by a(n) AA. French-speakingB. English-speakingC. German-speaking15 Which of the following words were not regarded as the language of the upper class in the Middle A ges? AA. DeerB. MuttonC. Pork16 In the C century English became dominant in Britain again.A. 12thB. 13thC. 14th17 Which of the following English poets is known as “the Father of English literature”? AA. G. ChaucerB. J. MiltonC. W. Shakespeare10 What are the main consequences of the Norman Conquest?The significance of Norman Conquest lies in the following aspects: the foundation of aristocracy, the fi nal unification of England, the great administrative process, a link to France, a great influence of French on English.Unit 21. One of the following took place during the Elizabethan age: BA. the making of the Magna CartaB. the defeat of the Spanish Armada by the English navyC. the rule of Alfred the GreatD. the defeat of King Harold by France2. In England, the monarch, D , declared that the Pope was no longer head of the Church of England.A. Bloody MaryB. Queen Elizabeth I.C. King Henry VD. King Henry VIII3. Three of the following were characteristics of the Elizabethan age. Which of the four is the exception?AA. Queen Elizabeth advocated the Divine Right and quarreled with Parliament.B. Protestantism gradually became the dominant faith.C. This was the age of literature when Shakespeare lived and when English literature blossomed.D. This was the age of adventure on the sea.4. Victorianism was characterized by the following except DA. It was in an age of imperialismB. It saw the great progress in sciences with Charles Darwin as a prominent figure.C. It was the age when the great progress was made in the field of communications.D. It was an age when the Battle of Hastings was won by the Duke of Wellington.?5. The Origin of Species was written by Charles Darwin .6. All English official documents bear the initials OHMS which stands for On His/Her Majesty's Service .7 In Britain, the executive power is in the hands of Cabinet .8. Queen Victoria takes the credit of the longest reign in British history.9. In the “Grab for Africa” Britain got the lion’s share, which confirmed its supremacy.1. The first colony at Jamestown in Virginia survived because the colonists discovered a way to earn mo ney. Which of the following was discovered by the Virginians? CA. Growing cottonB. Making a profit by fishingC. Growing tobacco in Virginia2. Which of the following states is called “ the Old Colony State ”? BA. PennsylvaniaB. MassachusettsC. Virginia3. Virginia is an American state named in honor of AA. Queen Elizabeth IB. Queen Mary IC. Queen Victoria4. Which of the following is the 50th state admitted into the US? CA. ArizonaB. AlaskaC. Hawaii5. Which of the following is not the motive of the English Puritans who went to New England as immigra nts? AA. They believed that the Church of England was not Catholic enoughB. They were persecuted in England.C. They wanted to establish a colony based on their own religious ideals.6. Thanksgiving Day was originally celebrated by people for AA. HarvestB. SafetyC. Freedom7. C was the only Founding Father to sign The Declaration of Independence, The United States Constitution, The Treaty of Alliance with France, and The Treaty of Paris. CA. George WashingtonB. Thomas JeffersonC. Benjamin Franklin8. The Confederacy was the government formed from 1861 to 1865 by B Southern states of the United States of America that had declared their secession from the U.S.A. 10B. 11C.129. The famous “this government of the people, by the people, for the people” was from AA. The Gettysburg AddressB. Emancipation ProclamationC. The Mayflower Compact10. What were the main features of the Elizabethan age?The Elizabethan age is often remembered by two things. The first is literature, especially the literature o f William Shakespeare. It was at the age that Shakespeare lived and English literature blossomed. The s econd is adventure on the sea The victory of English fleets marked the beginning of an English naval tra dition.11.Explain the atmosphere of Victorianism.Victorianism was an age of national development and national optimism. Tremendous social reform took place. The greatest one of all was made in the field of communications. Victorianism family life had the quality of stability and the victorias were extremely religious. It was also an age of imperialism.Unit 5I. Blank-filling1. The nickname for the USA national flag is “ Old Glory ”.2. The state of Virginia was named in honor of Queen Elizabeth I.3. As US national motto, “E Pluribus Unum”means “ Out of Many，One ”5. As pen name of Samuel Langhorne Clemens, Mark Twain means Mark Number Two .6. The largest state in terms of area is Alaska and the largest state in terms of population is California .7. The meaning of Mississippi is “ Great Waters ”.8. Some Puritans, called the Pilgrims, crossed the Atlantic in the ship Mayflower and settled at Plymo uth,Massachusetts in 1620.9. The writer O. Henry called Thanksgiving the one holiday that is purely American.10. The first shot in the American War of Independence was heard at the village of Lexington on April 19, 1775.11. In May, 1775, The 2nd Continental Congress met in Philadelphia and began to assume the functio ns of a national government.12. On June 14, 1776, the second Continental Congress officially appointed George Washington as co mmander-in-chief of the Continental Army.13. Thomas Jefferson was instructed by the Committee of Five to write the Declaration of Independe nce.14. The Independence Day of the United States is on July 4th .16. The famous “that this government of the people, by the people, for the people”was from the Gettys burg Address17. The 2nd Amendment in the Bill of Rights granted the American people the right to keep and bear ar ms .1. The Victorian novelists include the following except AA. William WordsworthB. William ThackerayC. Charles Dickens2. Which of the following is a tragedy written by Shakespeare? AA. OthelloB. The TempesC. Twelfth Night3. The most outstanding Victorian novelist in the aspect of literary merits was BA. Jonathan SwiftB. Charles DickensC. Charlotte Bronte4. “To be or not to be” is the quotation from which play by Shakespeare? CA. OthelloB. MacbethC. Hamlet5. Which fictional character is not created by Charles Dickens? CA. Oliver Twist.B. ScroogeC. Herzog6. Shakespeare lived under the reign of AA. Queen Elizabeth IB. Queen Mary IC. Queen Victoria7. Charles Dickens lived under the reign of CA. Queen ElizabethB. Queen Mary IC. Queen Victoria8. Which statement about Shakespeare is not right? CA. Shakespeare is a great master of the English languageB. Shakespeare started his career as an actorC. Shakespeare has a profound influence on the Christmas celebration nowadays9. Which statement about Dickens is not right? BA. Dickens incorporates autobiographical elements into his fictionB. Dickens is ignored during his life time but earns recognition afterwardsC. Dickens’ writing style is florid and poetic, with a strong comic touchII. Multiple-Choice21. Which of the following states is called “the Old Colony State”? BA. PennsylvaniaB. MassachusettsC. DelawareD.Georgia22. The term “Father of Waters”is used to refer to ____C______.A. the Amazon River C. the Mississippi RiverB. The Nile River D. The Hudson River23. Which of the following was not first grown by Native Americans? BA. potato C. pumpkinB. cabbage D. corn24. The first colony at James town in Virginia survived because the colonists discovered a way to earn money. Which of the following was discovered by the Virginians? BA. shipping cotton to EuropeB. growing tobacco in VirginiaC. making a profit by fishingD. growing cotton25. Three of the following were the motives of the English Puritans who went to New England as immigr ants. Which was the exception? AA. They believed that the Church of England was not Catholic enough.B. They believed that the Church of England was too Catholic in religious practices.C. They were persecuted in England.D. They wanted to established a colony based on their own religious ideals.26. Thanksgiving Day is originally celebrated by people for ___D__.A. healthB. safetyC. freedomD. harvest27. ___C__ was the only Founding Father to sign the Declaration of Independence, the United States C onstitution, the Treaty of Alliance with France, and the Treaty of Paris.A. George WashingtonB. Thomas JeffersonC. Benjamin FranklinD. John Adams28. The following words of wisdom were given by Benjamin Franklin except _B____A. A penny saved is a penny earned.B.All for one, one for all. ([法] Dumas pére大仲马)C. Time is money.D. Early to bed and early to rise, makes a man healthy, wealthy, and wise.29. George Washington served ___B__ term(s) as US President.A. oneB. twoC. threeD. four30. The author of Uncle Tom’s Cabin was _____C_______.A. Thomas PaineB. Barbara SmithC. Harriet Beecher StoweD. Mark TwainIII. Question35. What is the significance of the Second Continental Congress?In May 1775, the second Continental Congress met in Philadelphia and began to assume the functions o f a national government. It founded a Continental Army and Navy under the command of George Washi ngton.On June 11th, 1776, the second Continental Congress appointed a committee of five men to draft a Declaration of Independence.The young Thomas Jefferson was chosen by the committee to draft the Declaration of Independence, which the congress adopted on July 4th, 1776.37. What social problems did the American Civil War solve?The war resolved two fundamental questions that had divided the United States since 1776.It put an en d to slavery, which was completely abolished by the 13th Amendment to the constitution in 1865.It also decided, once and for all, that American was not a collection of semi-independent states, but a single i ndivisible nation.IV. True or False39. The first English colony was set in Jamestown in Virginia40. The bald eagle was chosen as the representative of the United States.41. Geographically the United States can be roughly divided into three parts—（The Atlantic Seacoast and the Appalachian Mountains in the east，the great Mississippi River Basin in the middle and the Rockies west to the Pacific Ocean）42. The Rocky Mountains are the backbone of North America.45. Pilgrim Fathers settled at Plymouth in 1620.46. The purpose of the First Continental Congress was to 放宽高压政策.47. Benjamin Franklin was the first to celebrate the American Dream.50. The Bill of Rights ensured the individual liberties.51. Mount Rushmore is famous for the faces of four American Presidents, who are G. Washington, T. Je fferson, A. Lincoln, and T. Roosevelt.52. The Battle of Gettysburg was fought on July 1 and 2, 1863 and is considered the turning point in the Civil War.1.which university is usually considered the first university in the world? BA. University of ConstantinopleB. University of BolognaC. University of Oxford2. What is the motto of Harvard University? AA. VeritasB. Lux et veritasC. Mens et Manus3. So far, how many US presidents have been produced by Yale University? CA. 3B. 4C. 54. Which of the following US universities is NOT the member of the Ivy League? CA. Yale UniversityB. Princeton UniversityC. MIT5. Oxford University began growing rapidly in A century.A. 12thB. 13thC. 14th6. From which university did John Harvard graduate? CA. Harvard UniversityB. Oxford UniversityC. Cambridge University7. What was the result of the first Boat Race between Oxford and Cambridge? AA. Oxford wonB. Cambridge wonC. It ended with a dead heat8. Which university was the site of the first practical electron microscope? BA. Stanford UniversityB. University of TorontoC. Australian National University9. According to Asian University Rankings, 2009, which university ranked the highest in Asi a? BA. Beijing UniversityB. University of TokyoC. University of Hong Kong美国枪支泛滥君主立宪制。

Product Data SheetPerkadox 14-40K-PD Di(tert-butylperoxyisopropyl) benzenePerkadox® 14-40K-PD is a 40% formulation on an inert carrier system (main carrier clay) in powder form.CAS number2212-81-9, 25155-25-3EINECS/ELINCS No.218-664-7TSCA statuslisted on inventoryMolecular weight338.5Active oxygen contentperoxide9.45%Concentration3.7-3.9%SpecificationsAppearance Off-white powderAssay39.0-41.0 %ApplicationsPerkadox® 14-40K-PD is a bifunctional peroxide which is used for the crosslinking of natural rubber and synthetic rubbers, as well as polyolefins. Rubber compounds containing Perkadox® 14-40K-PD have excellent scorch safety, and under certain conditions one step mixing is possible. Safe processing temperature: 135°C (rheometer ts2 > 20 min.). Typical crosslinking temperature: 175°C (rheometer t90 about 12 min.).Thermal stabilityOrganic peroxides are thermally unstable substances, which may undergo self-accelerating decomposition. The lowest temperature at which self-accelerating decomposition of a substance in the original packaging may occur is the Self-Accelerating Decomposition Temperature (SADT). The SADT is determined on the basis of the Heat Accumulation Storage Test.SADT80°CMethod The Heat Accumulation Storage Test is a recognized test method for thedetermination of the SADT of organic peroxides (see Recommendations on theTransport of Dangerous Goods, Manual of Tests and Criteria - United Nations, NewYork and Geneva).StorageDue to the relatively unstable nature of organic peroxides a loss of quality can be detected over a period of time. To minimize the loss of quality, Nouryon recommends a maximum storage temperature (Ts max. ) for each organic peroxide product.Ts Max.30°CNote When stored under the recommended storage conditions, Perkadox® 14-40K-PDwill remain within the Nouryon specifications for a period of at least 6 months afterdelivery.Packaging and transportThe standard packaging is a cardboard box for 50 lbs peroxide formulation. Both packaging and transport meet the international regulations. For the availability of other packed quantities consult your Nouryon representative. Perkadox®14-40K-PD is classified as Flammable solid, class 4. 1, UN 1325.Safety and handlingKeep containers tightly closed. Store and handle Perkadox® 14-40K-PD in a dry well-ventilated place away from sources of heat or ignition and direct sunlight. Never weigh out in the storage room. Avoid contact with reducing agents (e. g. amines), acids, alkalines and heavy metal compounds (e. g. accelerators, driers and metal soaps). Please refer to the Safety Data Sheet (SDS) for further information on the safe storage, use and handling of Perkadox® 14-40K-PD. This information should be thoroughly reviewed prior to acceptance of this product. The SDS is available at /sds-search.Major decomposition productsMethane, Acetone, tert-Butanol, Di(2-hydroxyisopropyl)benzene, Diacetylbenzene, Acetyl 2-hydroxyisopropyl benzeneAll information concerning this product and/or suggestions for handling and use contained herein are offered in good faith and are believed to be reliable.Nouryon, however, makes no warranty as to accuracy and/or sufficiency of such information and/or suggestions, as to the product's merchantability or fitness for any particular purpose, or that any suggested use will not infringe any patent. Nouryon does not accept any liability whatsoever arising out of the use of or reliance on this information, or out of the use or the performance of the product. Nothing contained herein shall be construed as granting or extending any license under any patent. Customer must determine for himself, by preliminary tests or otherwise, the suitability of this product for his purposes.The information contained herein supersedes all previously issued information on the subject matter covered. The customer may forward, distribute, and/or photocopy this document only if unaltered and complete, including all of its headers and footers, and should refrain from any unauthorized use. Don’t copythis document to a website.Perkadox® is a registered trademark of Nouryon Functional Chemicals B. V. or affiliates in one or more territories.Contact UsPolymer Specialties Americas************************Polymer Specialties Europe, Middle East, India and Africa*************************Polymer Specialties Asia Pacific************************2022-6-30© 2022Polymer crosslinking Perkadox 14-40K-PD。

possibly poisons leached from federal toxic waste sites, the U.S. Environmental2021 级高校英语四级模拟试卷（2021.11.21）Part I Writing (30 minutes)Directions: For this part, you are allowed 30 minutes to write a composition on the topic: T he I mportance o f k eeping A G ood M ood. Y ou s hould w rite a t l east 120 w ords according to the outline given below in Chinese:1. 人们每天都生活在压力之下2. 所以说保持一个好的心情是非常重要的3. 我的观点和缘由Part II Reading Comprehension (Skimming and Scanning) (15 minutes) Directions: I n t his p art, y ou w ill h ave 15 m inutes t o g o o ver t he p assage q uickly a nd answer the questions on Answer Sheet 1.For questions 1-7, m arkY (for YES) if the statement agrees with the information given in the passage;N (for NO) if the statement contradicts the information given in the passage;NG (for NOT GIVEN) if the information is not given in the passage.For q uestions 8-10, c omplete t he s entences w ith t he i nformation g iven i n t he passage. Gulf Wracked By Katrina's Latest Legacy-Disease, Poisons, MoldA month after Hurricane Katrina tore through the U.S. Gulf Coast, medical experts are now struggling with the latest crisis in the region; contamination(污染). Katrina left New Orleans and other communities tainted with oil, sewage, and Protection Agency (EPA) s ays.The pollution, combined with the lack of regular medical services in the region, has raised serious questions about the safety of New Orleans and other coastal towns as people longing for home begin to go back.I don't think New Orleans is safe for people to return to, from a public health and environmental health standpoint, said Miriam Aschkenasy, an environmental health expert working with Oxfam America in the region.Much of the contamination rests in the brown, filmy sediment(沉淀物) left behind by Katrina's polluted floodwaters.Recent EPA tests of the sediment confirmed high levels of E. coli bacteria, oil andgas chemicals, and lead, as well as varying quantities of arsenic.The health risks posed by the sediment are immediate, experts say, because the sludge(淤泥) is nearly impossible for returning residents to avoid. In New Orleans, it covers e very s urface that was flooded, from cars a nd n ow-dead lawns to t he e ntire contents of flooded homes, stores, hospitals, and schools.When p eople c ome b ack, t hey a re e xposed t o t he s ediment, s aid W ilma S ubra, a chemist from New Iberia, Louisiana, who is analyzing the sediment. It's in their yards and h ouses. Old Pollution ResurfacingPlaquemines Parish, a rural county on the peninsula south of New Orleans, is now covered with even more toxic sediment than it was two weeks ago, thanks to Hurricane R ita. Six inches up to one foot (15 to 30 centimeters) of sludge, Subra2021级大学英语四级模拟试卷reported.1Much o f t he s ludge i n P laquemines i s t he p roduct o f n earby b ayous a nd b ay bottoms, where sediment was lifted up by Katrina's and Rita's storm surges.The sediment has been polluted over the years with industrial chemicals and heavy metals, said Subra, who tested the sediment for the Southern Mutual Help Association, a nonprofit organization in New Iberia, Louisiana.These water bodies have received industrial wastes for decades, she said. This material h as t oxic c hemicals, metals, and o rganic p etrochemicals(石化产品). Matters have only been made worse by multiple oil spills caused by Katrina and Rita. According to the U.S. Coast Guard, 11 oil spills have occurred in southern Louisiana, t otaling 7.4 m illion g allons (28 m illion l iters) o f o il, m ost o f w hich h as b een contained.Bacteria levels are also especially high in the Plaquemines sludge, said Rodney Mallett, spokesperson for the Louisiana Department of Environmental Quality.The sewage treatment plants were underwater, he explained. Between the animal waste and the human waste, you've got a lot of bacteria.Protection KitsHealth a nd e nvironmental a gencies a re a dvising p eople t o a void c ontact w ith t he sludge. They recommend that people wear gloves, goggles, and dust masks, and that they wash promptly if exposure occurs.EPA officials are directing people to its Web site () to inform themselves ofthe contamination risks.But most people returning to the area don't have computers to get that information, said Erik Olson, an attorney for the Natural Resources Defense Council,an environmental a dvocacy group. If you [do] read the Web site, he added, you practically have to have a degree in chemistry to understand it.To b etter i nform p eople o f h ealth r isks, t he S outhern M utual H elp A ssociation a nd Oxfam America are developing a program to give every returning resident a protective kit.Each kit would contain waterproof suits, goggles(风镜), shoe covers, and masks, along with i nformation about potential h azards, Volunteers would g ive out t he kits a tthe security checkpoints that now stand at the major entrances to affected cities.The groups have made a hundred demonstration kits, which cost about $100 (U.S.) each to produce, and have shown them to state leaders in Louisiana.The g overnor i s r eally i n f avor o f t his, S ubra s aid. W e j ust h ave t o d etermine h owwe're going to fund them.Toxic Mold BloomsIn addition to the toxic sediment, sprawling blooms of mold have now taken hold in many f looded h omes. T he m old i s g rowing e verywhere-homes a re j ust c oated w ith i t, Subra said.The problem has become so widespread that federal health officials warned Wednesday of allergic reactions and toxic responses to the mold. Professionals shouldbe hired to clean mold that covers more than ten square feet (one square m e t e H r e)r,teams have been inoculating residents for tetanus and Hepatitis A and B. they urged. Hepatitis is a danger when people are exposed to sewage, through water or food, Those [surfaces] that can't be cleaned need to be removed, said Steven R e B d r d i,g g c s h i e e x f p l a i n e d.Tetanus can occur when people cut themselves on uncleanof the Air Pollution and Respiratory Health Branch of the U.S. Centers for Control and Prevention (CDC). m D a i t s e e r a i s a e ls, as may happen when cleaning deb T r h i e s.rudimentary根(本的) living conditions in many Kat-r s i t n r a u ck areas make it more likely that people will get sickThe effects of the mold are already surfacing in Mississippi, wh呼er吸e respi a r n a d to i r n y j(ured, Briggs said.的 ) problems are among the illnesses doctors there are reporting.2They have no electricity, no clean water, no air conditioning, she said. There a collapsed structures and stray animals. There are huge amounts of stray dogs, and people have been bitten.B riggs and other doctors in the area have been treatingWe're seeing a lot of asthma from inhaling the mold, said Richard Paat m,an t y ea c m ases of diarrhea, rashes, and-re u s p p p i e r r atory illnesses.leader of a temporary East Biloxi clinic. And mouth sores from the bad water.All of these conditions are to be expected after natural disasters, according to Due to contact with unclean water, 33 people in the flood zone have c o n t r C a D c C t.e d B u t it's too soon to know if these ailments are related to contamination, the Vibrio infections, according to the CDC. The infections are caused by a famCiDlCy'sofRoebuck said.We're looking at that question, he said. We'd like to know the bacteria that live in contaminated salt water. They can cause serious i l l n e a s n s s,w e e r s.p e c i a l l yin people with compromised immune systems.To date, six people have died from Vibrio infections.1. The passage gives a description of the contamination in New Orleans after Hurricane Katrina.People had open wound and walked through floodwater with sewage in it, CDC 2. Katrina left New Orleans and other communities tainted with oil and sewage. spokesperson Von Roebuck said. And these folks were having these wounds infec3t.edPlaquemines Parish is now covered with even more toxic sediment that it waswith Vibrio.Disaster Response Care two weeks ago.4. People are being advised to avoid contact with the sludge by health andThis is a highly contaminated area, said Susan Briggs, the physician o v e r e s n e v e i i r n o g n m e n t a l agencies.FEMA's disast-erresponse medical teams in Louisiana and Alabama. 5. The Southern Mutual Help Association and Oxfam America are developing aprogram to sell every returning resident a protective kit.6. The conditions in New Orleans after Hurricane Katrina is special.7. In addition to the toxic sediment, sprawling blooms of mold have now taken hold in many flooded homes, and it is growing everywhere.8. To date, six people have died from .9. The rudimentary living conditions in many Katrina-struck areas make it more likely that people will get .10. All of these conditions are to be expected after .Part IV Reading Comprehension (Reading in Depth) (25 minutes)Section A3Directions: I n t his s ection, t here i s a p assage w ith t en b lanks. Y ou a re r equired to select one word for each blank from a list of choices given in a word bank following the passage. Read the passage through carefully before making your choices. Each choice in bank is identified by a letter. Please mark the corresponding letter for each afraid to ask someone for a date.Many people are afraid to assert(表现)themselves. Dr. Alberti thinks it's because their self-respect is low. Our whole 48 is designed to make people distrust themselves, says Alberti. There's always ' 49 ' around-a parent, a teacher, a boss-who 'knows better'. These superiors often gain when they chip(减弱) away at your self-image.But Alberti and other scientists are doing something to help people 50 themselves. They 51 assertiveness training courses-At for short. In the AT courses p eople l earn t hat t hey h ave a r ight t o b e t hemselves. T hey l earn t o s peak o ut and feel good about doing so. They learn to be more 52 without hurting other people.In one way. learning to speak out is to 53 fear. A g roup t aking a c ourse w ill help the timid person to lose his fear. But AT uses an even stronger 54 -the need t o s hare. T he timid p erson s peaks o ut in t he g roup b ecause he wants t o t ell h ow he feels.Whether o r n ot y ou s peak u p f or y ourself d epends o n y our s elf-image. I f s omeone you face is more important than you, you may feel less of a person. You start toitem on Answer Sheet 2 with a single line through the center. You may not use any of 55 your own good sense.the words in the bank more than once.Questions 47 to 56 are based on the following passage.Have you ever been afraid to talk back when you were treated 47 ? Have you ever bought something just because the salesman talked you into it? Are youYou go by the other person's 56 . But, why should you? AT says you can get to feel good about yourself. And once you do, you can learn to speak out.[A] doubt [I] peace[B] active [J] demand[C] system [K] ask[D] offer [L] superior[E] unfairly [M] overcome[F] unfortunately [N] confidence[G] motive [O] roar[H] imageSection BDirections: There are 2 passages in this section. Each passage is followed by some questions or unfinished statements. For each of them there are four choices marked [A], [B], [C] and [D]. You should decide on the best choice and mark the corresponding letter on Answer Sheet 2 with a single line through the center. Passage OneQuestion 57 to 61 are based on the following passage.Among all the animals, the ape is most like human beings. Both people and apes have the similar brain structure, the similar nerve system, and the similar kind of blood.There are four kinds of apes: the chimpanzee(黑猩猩), the orangutan(猩猩), the gorilla(大猩4猩), and the gibbon(长臂猿). They live in the deep forests and warm tropical regions of Africa and of Southeast Asia, including Indonesia.All apes are covered with brown, reddish-brown, or black hair everywhere on their bodies e xcept t heir f aces, f eet, a nd h ands. T heir h ands e ach h ave f our f ingers a nd a thumb that helps them grip things the way our thumbs help us. But they also have a thumb on each foot instead of a big toe. Thus they can hold things with their feet also. Having short, weak legs, apes do not walk on the ground very much. However, their arms are very strong. This enables them to swing from branches and travel very quickly from tree to tree.These a nimals l ive i n s mall f amily g roups t hat m ove f rom p lace t o p lace i n s earch o f vegetables and fruits. They also eat eggs, small animals, nuts, and insects. When they are tired, they build nests in the trees. But they rarely sleep there for more than a night or two. Then they move on to look for more food.There are some differences among the following three kids of apes. The gibbon is never m ore t han t hree f eet h igh and w eight o nly about f ourteen p ounds. The g orilla grows to be six feet tall and weigh up to 600 pounds. The orangutan is smaller than the gorilla. It stands three to five feet tall and weigh up to 200 pounds. Chimpanzees a re t he s martest o f a ll a pes. T hey c an b e t aught t o s it a t a t able a nd eat, to dress themselves, and to do things that human children can do.57. What does the first paragraph tell us?[A] The ape looks like human beings most.[B] People and the ape think alike.[C] People and the ape behave alike.[D] The ape is the most intellectual animal in the world.58. Which of the following sentences is TRUE?[A] All apes are brown or black.[B] All parts of apes' bodies are covered with hair.[C] Apes have weak legs but very strong arms.[D] Apes' arms are strong enough to swim.59. Apes build nests in the trees but seldom sleep there for more than a night or two because .[A] They like to live in small family groups[B] They like to move from place to place in search of more food[C] They like to eat eggs, small animals, nuts and insects[D] It rains too often in the deep forests60. Among the three kinds of apes, .[A] the gorilla is the biggest[B] the gibbon is only three feet high but it is heavier than the orangutan[C] the orangutan is smaller than the gorilla and cleverer than the gibbon[D] the orangutan can stand up to a great height, but others cannot61. The last paragraph tells us that .[A] chimpanzees can do better than human children[B] chimpanzees can do many things that human children cannot do[C] human children can do many things that chimpanzees cannot do[D] the intelligence of chimpanzees is similar to that of human children5Passage TwoQuestions 62 to 66 are based on the following passage.Videodisc holds great promise of helping to meet the needs of American schoolchildren who have problems seeing, hearing, speaking, or socializing. Almost eleven percent of the students aged 3~21 in this country have an impairment that affects their ability to benefit from a regular education program. Handicapped students require special education because they are often markedly different from most children in one or more of the following ways: mentally retarded(进展迟缓的) learning-disabled, emotionally disturbed, deaf, visually handicapped, physically handicapped, or other health impairments. The education of these handicapped children is rewarding but challenging.A special education student usually needs a longer period of time to acquire information. Repetitive teaching techniques are often beneficial, and indefatigable(孜孜不倦的) consistency o n t he p art o f t he t eacher i s f requently n ecessary. Interactive videodisc c ourseware h as c haracteristics t hat c an b e c apitalized u pon t o m eet t he challenges t hat s pecial e ducation p oses. A v ideodisc p rogram i s i nfinitely p atient. Repetition of any videodisc lesson can continue endlessly, and designers can assure absolute consistency within a program. Most important, according to special educator William Healey of the University of Arizona, is that videodisc adds an extradimension of realism for children who need graphic representations.Healey explained that deaf and mentally retarded children especially have difficulty grasping figurative(比方的)language and higher-order language concepts. He believes that for special education, the power of videodisc lies in the ability of the technology to visually represent language concepts normally taken for granted bynon-handicapped persons. Complex figurative language forms such as idioms and metaphors come most readily to mind as being difficult for handicapped learners. 62. The special education mentioned in the text is mainly concerned with.[A] genius students from day-care centers to colleges[B] students who are fond of computer video games[C] teachers of language in the University of Arizona[D] students who are either mentally or physically disabled63. A videodisc courseware is beneficial to those who have study difficulties because .[A] its fancy design is very attractive[B] it allows the user to go back to where he wants to restudy[C] the content of it is healthy and promising[D] it is developed by university professors64. According to Professor Healey, we may infer that mentally retarded children perhaps .[A] need graphic representations in order to understand higher-order language concepts[B] are g ood a t s tudying E nglish i dioms b ut o ften f ail t o g rasp h igher-orderlanguage concepts[C] are not very patient with videodisc which helps them to understand the world concepts[D] tend t o b e deaf a s well and have difficulty learning the simple concept b eforeand after65. The best phrase that summarizes the main idea of the text is .6[A] handicapped students and their problems[B] videodisc and special e ducation[C] computer assisted teaching p rograms[D] normal children and handicapped kids66. The word impairment (Line 2, Para. 1) probably means .[A] habit[B] disability[C] misconception[D] beliefPart V Cloze (15 minutes)Directions: There are 20 blanks in the following passage. For each blank there areexperience for everyone who might be 86 . four choices marked [A], [B], [C] and [D] on the right side of the paper. You shouldchoose the ONE that best fits into the passage. Then mark the corresponding letteron Answer Sheet 2 with a single line through the center.Many p eople w rongly b elieve t hat w hen p eople r each o ld a ge, t heir f amilies p lacethem in nursing homes. They are left in the 67 of strangers for the rest oftheir lives. Their 68 children visit them onlyoccasionally, but more often, they do not have any 69visitors. The truth is that this idea is an unfortunate myth-an70 story. In fact, family members provide over 80 percent of the care71 elderly people need. Samuel Preston, a sociologist, studied 72the American family is changing. He reported that by the time the 73American couple reaches 40 years of age, they have more parents than children.74 , because people today live longer after an illness than people did years75 , family members must provide long term care. More psychologists havefound that all caregivers 76 a common characteristic: All caregivers believethat they are the best 77 for the job. In other words, they all felt that they78 do the job better than anyone else. Social workers 79 caregiversto find out why they took 80 the responsibility of caring for an elderlyrelative. Many caregivers believed they had 81 to help their relative. Somestated that helping others 82 them feel more useful. Others hoped that byhelping 83 now, t hey would d eserve care w hen they b ecame old and 84. Caring for the elderly and being taken care of can be a 85 satisfying67. [A] hands [B] arms [C] bodies [D] homes68. [A] growing [B] grown [C] grow [D] grows69. [A] constant [B] lasting [C] regular [D] normal70. [A] imaginary [B] imaginable [C] imaginative [D] imagery71. [A] that [B] this [C] those [D] these72. [A] when [B] how [C] what [D] where73. [A] common [B] ordinary [C] standard [D] average74. [A] Still [B] However [C] Moreover [D] Whereas75. [A] before [B] ago [C] later [D] lately76. [A] share [B] enjoy [C] divide [D] consent77. [A] person [B] people [C] character [D] man78. [A] would [B] will [C] could [D] can 779. [A] questioned [B] interviewed [C] inquired [D] interrogate80. [A] in [B] up [C] on [D] off81. [A] admiration [B] initiative [C] necessity [D] obligation82. [A] cause [B] enable [C] make [D] get83. [A] someone [B] anyone [C] everyone [D] anybody84. [A] elderly [B] dependent [C] d ependable [D] independent85. [A] similarly [B] differently [C] mutually [D] certainly86. [A] involved [B] excluded [C] included [D] consideredPart VI Translation (5 minutes)Directions: Complete the sentences on Answer Sheet 2 by translating into English the Chinese given in brackets.87. (幸亏遇到一位好心的出租车司机), Amy arrived at the test room in time.88. (这是一个生死攸关的问题) and therefore we must pay more attention to it.89. The problem of internet crime (近些年来引起了广泛关注).90. The computer isn't working properly; (确定有什么地方出了毛病).91. (应当留意的是) that pollution has become one of the thorniest problems in many big cities.8姓名学号学院答题卡89Part IV Reading Comprehension (Reading in Depth)Part VI Translation87. 88. 89. 90. 91.Part I Writing910Part I WritingThe Importance of Keeping A Good MoodIn today's increasingly competitive world it is essential to maintain a positive attitude towards life. To put it in a metaphor, keeping a good mood is a foundation upon which our life is built.Keeping a good mood is important because it can help us solve various problems in life. The following two situations can enable us to clearly see how a positive attitude helps us cope with unpleasant things. Take English learning for example. In our effort to grasp English, mistakes are unavoidable. From one perspective mistakes are annoying, but a positive attitude can make us realize that only through makingmistakes c an a learner be expected to make p rogress. Sometimes one may come down w ith a s erious c old, f eeling d epressed. B ut a c hange i n a ttitude w ill e nable u s t o look at the matter from a positive perspective. The illness may teach us the importance of health.As we c an s ee, k eeping a g ood m ood c an h elp u s t o d eal with mistakes i n t he r ight way and find comfort in time of sorrow. Its importance cannot be denied.Part II Reading Comprehension(Skimming and Scanning)1. Y 通读全文后，即可发觉本文描写了新奥尔良被“卡特利娜”飓风攻击后的景象，可知题干表述正确。