Cardiopulmonary and metabolic responses during a 2-day CPET in myalgic encephalomyelitis/chronic fatigue syndrome: translating reduced oxygen consumption to impairment status to treatment considerations.

BACKGROUND: Post-exertional malaise (PEM), the hallmark symptom of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), represents a constellation of abnormal responses to physical, cognitive, and/or emotional exertion including profound fatigue, cognitive dysfunction, and exertion intolerance, among numerous other maladies. Two sequential cardiopulmonary exercise tests (2-d CPET) provide objective evidence of abnormal responses to exertion in ME/CFS but validated only in studies with small sample sizes. Further, translation of results to impairment status and approaches to symptom reduction are lacking. METHODS: Participants with ME/CFS (Canadian Criteria; n = 84) and sedentary controls (CTL; n = 71) completed two CPETs on a cycle ergometer separated by 24 h. Two-way repeated measures ANOVA compared CPET measures at rest, ventilatory/anaerobic threshold (VAT), and peak effort between phenotypes and CPETs. Intraclass correlations described stability of CPET measures across tests, and relevant objective CPET data indicated impairment status. A subset of case-control pairs (n = 55) matched for aerobic capacity, age, and sex, were also analyzed. RESULTS: Unlike CTL, ME/CFS failed to reproduce CPET-1 measures during CPET-2 with significant declines at peak exertion in work, exercise time, V ˙ e, V ˙ O2, V ˙ CO2, V ˙ T, HR, O2pulse, DBP, and RPP. Likewise, CPET-2 declines were observed at VAT for V ˙ e/ V ˙ CO2, PetCO2, O2pulse, work, V ˙ O2 and SBP. Perception of effort (RPE) exceeded maximum effort criteria for ME/CFS and CTL on both CPETs. Results were similar in matched pairs. Intraclass correlations revealed greater stability in CPET variables across test days in CTL compared to ME/CFS owing to CPET-2 declines in ME/CFS. Lastly, CPET-2 data signaled more severe impairment status for ME/CFS compared to CPET-1. CONCLUSIONS: Presently, this is the largest 2-d CPET study of ME/CFS to substantiate impaired recovery in ME/CFS following an exertional stressor. Abnormal post-exertional CPET responses persisted compared to CTL matched for aerobic capacity, indicating that fitness level does not predispose to exertion intolerance in ME/CFS. Moreover, contributions to exertion intolerance in ME/CFS by disrupted cardiac, pulmonary, and metabolic factors implicates autonomic nervous system dysregulation of blood flow and oxygen delivery for energy metabolism. The observable declines in post-exertional energy metabolism translate notably to a worsening of impairment status. Treatment considerations to address tangible reductions in physiological function are proffered. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, retrospectively registered, ID# NCT04026425, date of registration: 2019-07-17.

Virtuous organizations: Desire, consumption and human flourishing in an era of climate change.

The notion of virtuous organizations has an established place in the business ethics/organization studies literature. But this conceptualization drew principally on Alasdair MacIntyre's After Virtue. His more recent work Ethics in the Conflicts of Modernity, with its focus on desire, consumption and human flourishing, demands a revisiting of the original concept. The first aim of this paper, therefore, is to provide an extended theory of the notion of the virtuous organization. An obvious application of this extended theory is to the issue of climate change. In exploring this, the paper has a further aim which is to respond to Banerjee et al.'s call for more theory building that articulates post-growth possibilities at the organization level in relation to the multiple challenges which society faces in response to the changing climate. The paper begins by summarizing the current conceptual framework of the virtuous organization while recognizing critiques of MacIntyre's work and its organizational application. It then turns to the issues of desire and consumption highlighted in MacIntyre's latest book, drawing also on an extended literature in these areas including insights from Girard's work, and concluding with MacIntyre's contentions in relation to human flourishing. This leads to the extended conceptual framework which is then applied to the issue of climate change. The particular theoretical contribution of the paper is to understand virtuous organizations as playing an important role in the redirection and re-education of desires, leading to the pursuit of goods that we have good reason to desire, and so to the good for individuals and communities, and ultimately to human flourishing within ecological limits. The similarities with and differences from the degrowth/post-growth movement are explored to demonstrate the distinctive contribution a MacIntyrean approach makes. The practical implications of this theoretical contribution are then spelled out, including a consideration of the potential ubiquity or otherwise of this approach, before conclusions are drawn.