SMILE-RA-SELF-MANAGEMENT INDIVIDUALISED LEARNING ENVIRONMENT in RHEUMATOID ARTHRITIS

Background: An important but insufficient aspect of care in people with infam-matory arthritis (IA) is empowering them to acquire good understanding of their disease and build ability to deal effectively with the practical, physical and psychological impacts of it. This extends beyond drug therapy and emphasises the ability to self-manage, with the right support, as an essential component of care. Good self-efficacy and coping skills reduce health and fnancial burden to the individual as well as the health service, beneftting society overall. Provision of excellent supported self-management education is at the heart of what NRAS does and it was due to the difficulty of getting Commissioners to fund our face-to-face group self-management that led to our building an e-learning programme to expand on and replace our 6-week programme. Objectives: To co-create an intuitive, easy to use, modular e-learning programme, free for all and which health professionals (HCPs) could refer their patients to. This makes supported self-management and evidence-based education accessible to all, wherever they live. SMILE enables HCPs to meet both NICE guideline and quality standards in RA against which rheumatology units in England and Wales are currently audited, as well as EULAR Recommendations for self-management strategies in infammatory arthritis. Methods: In 2019 with initial funding in place, we worked with our provider to help us realise our goal of developing a state-of-the art e-learning experience in a modular format for people with RA. The programme had to be 1) simple to use;2) interactive;3) innovative and engaging;4) able to measure impact through achievement of learning objectives and use of a validated patient reported outcome measure. The programme also had to be integrable with our Salesforce database enabling us to collect data and target resources to individuals, driven by identifed need. Results: Delayed by COVID, we launched with 4 modules on 17/09/2021. The 4 modules comprise: Foundation Module covering the importance of self-management which has the RA Impact of Disease PROM embedded;Newly Diagnosed;Meet the Team and Managing Pain and Flares. A ffth module on Medicines in RA will be launched 1st quarter 2022 and 4 further modules will be uploaded in 2022. To date (26/01/22), 760 people have registered, of which 313 have completed a baseline RAID and this reveals that <50% are achieving minimal acceptable state of 3 or less. Over 78% of registrants are not NRAS members, and 634 modules have been completed. Early indications are that almost all are achieving learning objectives. More data will be available by June 2022. Conclusion: Early indications demonstrate that people are successfully engaging with the programme and we have marketing activity lined up to raise further awareness of the value of SMILE with both potential users and rheumatology teams in 2022. Massive workforce issues together with signifcant backlogs of existing patients caused by the pandemic, have restricted the ability of Teams to provide education and self-management support for their patients. SMILE offers high quality, evidence-based learning opportunities for their patients and has been co-created with health professionals and people with RA at every step. With remote consultations here to stay, the importance of patients having access to evidence based online learning which they can tailor to their specifc needs and improve their self-efficacy is even more critical.

NRAS VIRTUAL GROUPS

Background/Aims NRAS Groups have long provided an opportunity for those with RA to meet others in a similar situation for mutual benefit. Attendees have told us how they enjoy meeting in a non-clinical environment to learn more about the condition and receive encouragement from others. When COVID-19 hit and NRAS groups were unable to meet in person and most people living with RA had to shield this intensified the feelings of isolation. NRAS responded to this need by establishing online regional groups and JoinTogether virtual groups. Methods 1. NRAS offered training and support to facilitate online group meetings to its regional groups' leaders. Volunteers were provided with a dedicated NRAS email address, access to an Office 365 portal and Zoom account and GDPR training. NRAS colleagues attended introductory meetings to support the Group Leaders and continue to provide technical support, promotion via website and social media as well as general advice. 2. Recognising a need to reach a wider audience who were not accessing the regional groups - i.e. younger and perhaps 'time poor' due to working etc. - NRAS took advantage of the move to online engagement and also initiated the exclusively online JoinTogether topic-based groups, using a Volunteer Lead model. Results Regional Groups: Almost half of the regional groups signed up to the online training. Many found that the online meetings brought very positive benefits e.g. they were able to reach a wider audience as attendees were not put off by having to travel and could still attend if they were feeling fatigued. Many reported it was easier to attract NHS rheumatology health professionals to give talks as they did not have to travel and could even join meetings from home in the evenings. Some groups in adjoining areas joined forces so they could expand their offerings. JoinTogether Groups: Volunteer Lead, with NRAS support, has now set up 5 topic-based groups, each led by two co-ordinators. Topics are: Exercise and Back to Sport;Parenting With Inflammatory Arthritis;18-35 year olds with RA or JIA: Working with Inflammatory Arthritis and Parents with children with JIA. These groups are thriving and attracting new audiences. They are very much volunteer led and attendees play a key role in directing the development of the JoinTogether groups to suit their needs. Conclusion NRAS virtual groups have allowed those living with RA or JIA to maintain contact with a community, with shared experiences, throughout the pandemic. They have also been instrumental in attracting attendees from audiences NRAS had traditionally found harder to access. The Volunteer Lead model that has been successfully implemented for the JoinTogether groups can now be expanded to other areas, enabling NRAS to increase capacity for delivering vital services.

NRAS YOUNG VOICES PANEL

Background/Aims NRAS understands that inflammatory arthritis affects people of all ages. In early 2020 NRAS decided that a voice of the JIA community was needed to inform and provide guidance on a framework for JIA services at NRAS. The group would also empower younger people with RA, who are often frustrated by the perception that the condition 'only affects elderly people'. Methods NRAS recruited a group of young people with lived experience of JIA and RA to reflect the target population of the JIA service age range. The group were drawn from diverse backgrounds and now it includes representation from the Cabinet office, health care professionals and experts in youth engagement and digital marketing together with PhD students and creative professionals. Results Throughout the last 12 months the Young Voices Panel have developed and prioritised the service framework for young people with inflammatory arthritis and JIA-at-NRAS. One of the main priorities was peer-topeer support and now having the JIA Parents online group we can offer this to parents, alongside our other new JoinTogether online groups as well (e.g. 18 to 35year olds, Working with inflammatory arthritis, Parenting with inflammatory arthritis and Exercise and Back to Sport with inflammatory arthritis). The Young Voices have shared their stories and experiences in Facebook Live sessions during RAAW, Wear Purple for JIA in November 2020 and recently for the new #WearPurpleForJIA Wellbeing Week in June 2021. Some of the Young Voices were also part of the focus group for the new Medicines in JIA booklet which has now been launched. They spoke with parents during our zoom event Coping with JIA during COVID-19 in March to show parents that their children can thrive in life whilst learning to manage to the ups and downs that RA/ JIA has. They also shared their experiences with young people at the young person's event Navigating your future with inflammatory arthritis in April discussing how to tell friends and partners about their disease and where to find support at university and explain to employers about the conditions. They have also helped NRAS focus on what young people may want from the new JIA digital membership and participated in raising awareness for young people with JIA/RA podcasts and articles for Enable magazine. Conclusion The Young Voices Panel have been an integral part of NRAS and will continue to develop the service framework and be the voice of young people with JIA/RA. Feedback from events: 'Thank you for sharing your stories and experiences, you are inspirational'. 'I am so glad that young people are getting of a voice with regard to being diagnosed with arthritis'.

A new translocation partner for CBFB in acute myeloid leukemia, t(10;16)(p13;q22)

Cytogenetic abnormalities involving chromosome 16 are found in 5– 8% of acute myeloid leukemia (AML). These are typically a pericentric inversion inv(16)(p13.1q22) or a translocation, t(16;16)(p13.1;q22), involving the MYH11 and CBFB genes localized to chromosome 16p13.1 and 16q22, respectively. In addition, less common rearrangements include deletion of the long arm of chromosome 16, del(16) (q22), and cryptic insertions involving the MYH11 and the CBFB genes with otherwise normal karyotypes. In this report, we present the first AML case with a new translocation involving the CBFB gene. The more common CBFB - MYH11 fusion product resulting from the inversion and/or translocation of chromosome(s) 16 leads to an AML with monocytic and granulocytic differentiation and abnormal eosinophil component with large, purple to violet color eosinophilic granules. This entity typically corresponds to the adult AML-M4Eo in French-American- British (FAB) Classification and now called AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22);CBFB-MYH1 in the new 2017 WHO Classification. Patients may present with myeloid sarcoma at initial diagnosis or at relapse. We present a case of an 80-year-old male with a history of prostate cancer post radiotherapy who was referred for COVID-19 testing. A complete blood count with differential revealed neutropenia and a macrocytic anemia. A bone marrow biopsy and a bone marrow aspirate confirmed a diagnosis of AML with 33% blasts including myeloblasts and promonocytes. Interphase fluorescence in situ hybridization (FISH) analysis with a break-apart probe for CBFB showed an abnormal hybridization pattern consistent with rearrangement of CBFB in 66% of nuclei. Chromosome analysis revealed an abnormal karyotype with two related clones: 47,XY, t(10;16)(p13;q22),+22[4]/48,idem,+8[16]. Sequential GTG-FISH confirmed that the 3’ region of CBFB was translocated to 10p13 in the t(10;16) and the 5’ region remained on 16q. Based on the karyotype, the patient’s bone barrow exhibits clonal evolution having acquired additional chromosome abnormalities (trisomy 22 and trisomy 8). Molecular studies by next generation sequencing showed NRAS p.Gln61Lys mutation with a VAF of 11.21%. No genomic alterations were detected in KIT, KRAS or FLT3 genes. AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22) is associated with a high rate of complete remission and favorable overall survival when treated with intensive consolidation therapy. However, their prognostic advantage may be affected by additional cytogenetic abnormalities and/or other gene mutations. Specifically, trisomy 22, is a frequent abnormality additional to inv(16) detected as a secondary finding which has been associated with an improved outcome when compared to the prognosis associated with inv(16) alone. Furthermore, KIT (in 30–40%), FLT3 (in 14%), NRAS (in 45%) and KRAS (in 13%) mutations are common in this AML type. The prognostic implications of KIT mutation (especially involving exon 8) do not appear to be significantly poor prognostic compared to other AML types. On the other hand FLT3-TKD mutations and trisomy 8 are associated with a worse outcome. The patient is currently receiving Vidaza 75 mg/m2, days 1–7 of a 28 days cycle with Venetoclax mg daily of a 28-day cycle and his clinical prognosis is currently unclear. Further analysis by DNA sequencing may help to characterize the molecular nature of the fusion gene product resulting from the novel t(10;16)(p13;q22). To the best of our knowledge, this is the first reported case of an AML patient with translocation t(10;16)(p13;q22) involving the CBFB gene. Given the rarity and lack of additional information regarding the effects of this abnormality, the prognosis and survival cannot be predicted.

Inhibition of De Novo Pyrimidine Synthesis Depletes Acute Myleogenous Leukemia Stem Cells (LSCs) Burden and Triggers Apoptosis and Differentiation Associated with Oxidative Stress

Background: De novo nucleotide synthesis is necessary to meet the enormous demand for nucleotides, other macromolecules associated with acute myeloid leukemia (AML) progression 1, 2, 34. Hence, we hypothesized that targeting de novo nucleotide synthesis would lead to the depletion of the nucleotide pool, pyrimidine starvation and increase oxidative stress preferentially in leukemic cells compared to their non-malignant counterparts, impacting proliferative and differentiation pathways. Emvododstat (PTC299) is an inhibitor of dihydroorotate dehydrogenase (DHODH), a rate-limiting enzyme for de novo pyrimidine nucleotide synthesis that is currently in a clinical trial for the treatment of AML. Objectives: The goals of these studies were to understand the emvododstat-mediated effects on leukemia growth, differentiation and impact on Leukemia Stem Cells(LSCs). Comprehensive analyses of mitochondrial function, metabolic signaling in PI3K/AKT pathways, apoptotic signatures, and DNA damage responses were carried out. The rationale for clinical testing emvododstat was confirmed in an AML-PDX model. Results: Emvododstat treatment in cytarabine-resistant AML cells and primary AML blasts induced apoptosis, differentiation, and reduced proliferation, with corresponding decreased in cell number and increases in annexin V- and CD14-positive cells. Indeed, the inhibition of de novo nucleotide synthesis compromises the dynamic metabolic landscape and mitochondrial function, as indicated by alterations in the oxygen consumption rate (OCR) and mitochondrial ROS/membrane potential and corresponding differentiation, apoptosis, and/or inhibition of proliferation of LSCs. These effects can be reversed by the addition of exogenous uridine and orotate. Further immunoblotting and mass cytometry (CyTOF) analyses demonstrated changes in apoptotic and cell signaling proteins (cleaved PARP, cleaved caspase-3) and DNA damage responses (TP53, γH2AX) and PI3/AKT pathway downregulation in response to emvododstat. Importantly, emvododstat treatment reduced leukemic cell burden in a mouse model of AML PDX ( Complex karyotype, mutation in ASXL1, IDH2, NRAS), decreased levels of leukemia stem cells frequency (1 in 522,460 Vs 1 in 3,623,599 in vehicle vs emvododstat treated mice), and improved survival. The median survival 40 days vs. 30 days, P=0.0002 in primary transplantation and 36 days vs 53.5 days, P=0.005 in secondary transpantation in a PDX mouse model of human AML. This corresponded with a reduction in the bone marrow burden of leukemia and increased expression of differentiation markers in mice treated with emvododstat (Fig. 1). These data demonstrate effect of emvododstat on mitochondrial functions. Conclusion: Inhibition of de novo pyrimidine synthesis triggers differentiation, apoptosis, and depletes LSCs in AML models. Emvododstat is a novel dihydroorotate dehydrogenase inhibitor being tested in a clinical trial for the treatment of myeloid malignancies and COVID-19. Keywords: AML, emvododstat, DHODH, apoptosis, differentiation References: 1 Thomas, D. & Majeti, R. Biology and relevance of human acute myeloid leukemia stem cells. Blood 129, 1577-1585, doi:10.1182/blood-2016-10-696054 (2017). 2 Quek, L. et al. Genetically distinct leukemic stem cells in human CD34- acute myeloid leukemia are arrested at a hemopoietic precursor-like stage. The Journal of experimental medicine 213, 1513-1535, doi:10.1084/jem.20151775 (2016). 3 Villa, E., Ali, E. S., Sahu, U. & Ben-Sahra, I. Cancer Cells Tune the Signaling Pathways to Empower de Novo Synthesis of Nucleotides. Cancers (Basel) 11, doi:10.3390/cancers11050688 (2019). 4 DeBerardinis, R. J. & Chandel, N. S. Fundamentals of cancer metabolism. Sci Adv 2, e1600200, doi:10.1126/sciadv.1600200 (2016). [Formula presented] Disclosures: Weetall: PTC therapeutics: Current Employment. Sheedy: PTC therapeutics: Current Employment. Ray: PTC therapeutics: Current Employment. Andreeff: Karyopharm: Research Funding;AstraZeneca: Research Funding;Oxford Biomedica UK: Research Funding;Aptose: Consultancy;Daiich -Sankyo: Consultancy, Research Funding;Syndax: Consultancy;Breast Cancer Research Foundation: Research Funding;Reata, Aptose, Eutropics, SentiBio;Chimerix, Oncolyze: Current holder of individual stocks in a privately-held company;Novartis, Cancer UK;Leukemia & Lymphoma Society (LLS), German Research Council;NCI-RDCRN (Rare Disease Clin Network), CLL Foundation;Novartis: Membership on an entity's Board of Directors or advisory committees;Senti-Bio: Consultancy;Medicxi: Consultancy;ONO Pharmaceuticals: Research Funding;Amgen: Research Funding;Glycomimetics: Consultancy. Borthakur: ArgenX: Membership on an entity's Board of Directors or advisory committees;Protagonist: Consultancy;Astex: Research Funding;University of Texas MD Anderson Cancer Center: Current Employment;Ryvu: Research Funding;Takeda: Membership on an entity's Board of Directors or advisory committees;Novartis: Consultancy, Membership on an entity's Board of Directors or advisory committees;GSK: Consultancy.

Identification of a Conserved Intracellular Loop (CIL) Structure That Scaffolds PIP3 to Amplify Oncogenic Signaling during Malignant B-Cell Transformation

Background: Within seconds of antigen-encounter, B-cell receptor (BCR) signaling induces dramatic changes of cell membrane lipid composition, including >40-fold increases of local PIP3-concentrations within lipid rafts. While several structural elements, including pleckstrin homology (PH) domains have been identified as PIP3-binding proteins, the underlying mechanisms that amplify BCR-signaling to assemble large signaling complexes within lipid rafts within 15 to 30 seconds, remained elusive. To understand the mechanistic and biophysical requirements for PIP3 accumulation during normal B-cell activation and acute oncogenic transformation, we identified PIP3-interacting proteins by cell-surface proteomic analyses. Results: In addition to proteins known to bind PIP3 with their PH-domains, we identified the short 133 aa protein IFITM3 (interferon-inducible transmembrane protein 3) as a top-ranking PIP3 scaffold. This was unexpected because IFITM3 was previously identified as endosomal protein that blocks viral infection by stiffening endosomal membranes to firmly contain viral cargo. Previous studies revealed that polymorphisms that lead to the expression of truncated IFITM3 are associated with increased susceptibility to viral infections, including SARS-CoV2. Among known cell membrane lipids, PIP3 has the highest negative charge. Instead of a PH-domain, IFITM3 laterally sequestered PIP3 through electrostatic interactions with two basic lysine residues (K83 and K104) located at the membrane-solution interface. Together with three other basic lysine and arginine residues K83 and K104 form a conserved intracellular loop (CIL), which enable IFITM3 to efficiently capture two PIP3 molecules. Bivalent PIP3-binding of the IFITM3-CIL enables a crosslinking mechanism that results in dramatic amplification of B-cell activation signals and clustering of large signaling complexes within lipid rafts. In normal resting B-cells, Ifitm3 was minimally expressed and mainly localized in endosomes. However, B-cell activation and oncogenic kinases induced phosphorylation at IFITM3-Y20, resulting in translocation of IFITM3 from endosomes and massive accumulation at the cell surface. Ifitm3ˉ /ˉ naïve B-cells developed at normal numbers, however, activation by antigen encounter was compromised. In Ifitm3ˉ /ˉ B-cells, lipid rafts were depleted of PIP3, resulting in defective expression of >60 lipid raft-associated surface receptors and impaired PI3K-signaling. Ifitm3ˉ /ˉ B-cells were unable to undergo affinity maturation and di not contribute to germinal center formation upon immunization. Analyses of gene expression and clinical outcome data from patients in six clinical cohorts for pediatric and adult B-ALL, mantle cell lymphoma, CLL and DLBCL, we consistently identified IFITM3 as a top-ranking predictor of poor clinical outcome. Inducible activation of BCR-ABL1 and NRAS G12D rapidly induced development of B-ALL but failed to transform and initiate B-ALL from Ifitm3ˉ /ˉ B-cell precursors. Conversely, the phospho-mimetic IFITM3-Y20E mutation, mimicking phosphorylation of the IFITM3 N-terminus at Y20 induced constitutive membrane localization of IFITM3, spontaneous aggregation of large oncogenic signaling complexes and readily initiated transformation in a genetic model of pre-malignant B-cells. Conclusions: We conclude that phosphorylation of IFITM3 upon B-cell activation induces a dynamic switch from antiviral effector functions in endosomes to oncogenic signal-amplification at the cell-surface. IFITM3-dependent amplification of PI3K-signaling is critical to enable rapid expansion of activated B-cells. In addition, multiple oncogenes depend on IFITM3 to assemble PIP3-dependent signaling complexes and amplify PI3K-signaling for malignant transformation and initiation of B-lymphoid leukemia and lymphoma. [Formula presented] Disclosures: Weinstock: SecuraBio: Consultancy;ASELL: Consultancy;Bantam: Consultancy;Abcuro: Research Funding;Verastem: Research Funding;Daiichi Sankyo: Consultancy, Research Funding;AstraZeneca: Consultanc ;Travera: Other: Founder/Equity;Ajax: Other: Founder/Equity.