Journal of IiME Volume 9 Issue 1 physiological and immune function. Together they continue to analyze this data and other data collected to better understand how to help those with ME/CFS. Abstract: Post exertion malaise (PEM) is an exacerbation of the symptom profile of an ME patient following physical, cognitive or emotional stress. Physical stress that exceeds the physiologic threshold of aerobic metabolism necessitates energy production from anaerobic metabolism to meet energy demands of work. Energy production via anaerobic metabolism is fast acting and important to meet immediate and short-term energy demands, but produces metabolites that contribute to physiologic fatigue. A dependency on anaerobic energy production for longer duration activities (> 2 min) will exceed a physiologic threshold of aerobic energy production (aka anaerobic threshold) and contribute to fatigue. In healthy individuals, the physiologic consequence of exceeding anaerobic threshold is a reduction in work to an intensity at which aerobic metabolism can supply the preponderance of energy. The reduction in work also enables recovery of anaerobic energy-producing processes. In contrast, exercise studies of ME patients reveal an impaired ability of aerobic metabolism to facilitate recovery following anaerobic work. In this case, the ME patient will rely predominantly on anaerobic metabolism to power even low-level activities that would not normally provoke fatigue. The altered metabolism will also exacerbate the profile of ME symptoms that are specific to the patient, possibly causing new symptoms to emerge. With judicious management of physical activity intensity, duration, and recovery, it is easier to avoid post-exertion symptom exacerbation (PEM) than it is to recover from it. May 2015 Strategies and guidelines for physical activity management will be discussed with goals of avoiding symptom flares and improving movement efficiency, and with hope for enhancing overall well-being. Professor Olav Mella / Dr Øystein Fluge Multi-centre Rituximab Clinical Trial for ME/CFS Dr Øystein Fluge received medical degree in 1988 at the University of Bergen, and is a specialist in oncology since 2004. He has worked as a Research Fellow with support from the Norwegian Cancer Society and is now chief physician at the Cancer Department, Haukeland University Hospital. Doctoral work emanates from the Surgical Institute and Department of Molecular Biology, University of Bergen. Professor Mella has performed clinical trials to test the benefit of B-cell depletion therapy using rituximab in ME/CFS patients. Dr. Olav Mella of Haukeland University Hospital in Bergen, Norway began his investigation of rituximab’s effects on CFS after treating several Hodgkin’s Lymphoma patients who had long standing cases of CFS prior to developing cancer. In 2011 Professor Mella and Dr Fluge published a paper "Benefit from BLymphocyte Depletion Using the Anti-CD20 Invest in ME (Charity Nr. 1114035) www.investinme.org Page 52 of 57

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