Work-Life Balance among Physicians in Jordan.

BACKGROUND AND OBJECTIVES: We aimed to assess the work-life balance, job satisfaction, and life satisfaction and their correlates among physicians in Jordan. MATERIALS AND METHODS: This study utilized an online questionnaire to collect information about work-life balance and related factors from practicing physicians in Jordan from August 2021 until April 2022. The survey consisted of 37 detailed self-report questions covering seven main categories: demographics, professional and academic information, impact of work on personal life, impact of personal life on work, work/personal life enhancement, the Andrew and Withney Job Satisfaction scale, and the Satisfaction with Life Scale developed by Diener et al. Results: The study included 625 participants. Overall, 62.9% were found to have a work-life conflict. The work-life balance score was negatively correlated with age, number of children, and years practicing medicine, while it was positively correlated with number of hours per week and number of calls. Regarding job and life satisfaction, 22.1% had a score indicating job dissatisfaction, while 20.5% disagreed with the statements indicating life satisfaction. CONCLUSION: Our study demonstrates that work-life conflict is highly prevalent among Jordanian physicians and highlights the significance of work-life balance in supporting physicians' well-being and performance.

Studying possible cross-protection of Canada geese preexposed to North American low pathogenicity avian influenza virus strains (H3N8, H4N6, and H5N2) against an H5N1 highly pathogenic avian influenza challenge.

Highly pathogenic avian influenza (HPAI) H5N1 virus infections have caused unprecedented morbidity and mortality in different species of domestic and wild birds in Asia, Europe, and Africa. In our previous study, we demonstrated the susceptibility and potential epidemiologic importance of H5N1 HPAI virus infections in Canada geese. In this study, we investigated the potential of preexposure with North American lineage H3N8, H4N6, and H5N2 low pathogenicity avian influenza (LPAI) viruses to cross-protect Canada geese against a lethal H5N1 HPAI virus challenge. Based on our results, birds that were primed and boosted with an H5N2 LPAI virus survived a lethal H5N1 challenge. In contrast, only two of five birds from the H3N8 group and none of the birds preexposed to H4N6 survived a lethal H5N1 challenge. In vitro cell proliferation assays demonstrated that peripheral blood mononuclear cells collected from each group were no better stimulated by homologous vs. heterologous antigens.

Dietary induction of NQO1 increases the antitumour activity of mitomycin C in human colon tumours in vivo.

The bioreductive antitumour agent, mitomycin C (MMC), requires activation by reductive enzymes like NAD(P)H:quinone oxidoreductase 1 (NQO1). We used a novel approach to increase MMC efficacy by selectively inducing NQO1 in tumour cells in vivo. CD-1 nude mice were implanted with HCT116 cells, and fed control diet or diet containing 0.3% of the NQO1 inducer, dimethyl fumarate (DMF). The mice were then treated with saline, 2.0, 3.5 or 2.0 mg kg(-1) MMC and dicoumarol, an NQO1 inhibitor. The DMF diet increased NQO1 activity by 2.5-fold in the tumours, but had no effect in marrow cells. Mice given control diet/2.0 mg kg(-1) MMC had tumours with the same volume as control mice; however, mice given DMF diet/2.0 mg kg(-1) MMC had significantly smaller tumours. Tumour volumes in mice given DMF/2.0 mg kg(-1) MMC were similar to those in mice given control diet/3.5 mg kg(-1) MMC. Tumour inhibition was partially reversed in mice given DMF/2.0 mg kg(-1) MMC and dicoumarol. DMF diet/2.0 mg kg(-1) MMC treatment did not increase myelosuppression and did not produce any organ toxicity. These results provide strong evidence that dietary inducers of NQO1 can increase the antitumour activity of bioreductive agents like MMC without increasing toxicity.

Factors influencing the induction of DT-diaphorase activity by 1,2-dithiole-3-thione in human tumor cell lines.

NAD(P)H:(quinone acceptor)oxidoreductase (DT-diaphorase) is a two-electron reducing enzyme that activates bioreductive antitumor agents and is induced by a wide variety of compounds including 1,2-dithiole-3-thione (D3T). We investigated factors influencing DT-diaphorase induction in fourteen human tumor cell lines. Four cell lines had basal DT-diaphorase activity that was increased by D3T treatment (group A), six cell lines had basal DT-diaphorase activity but the activity was not increased by D3T (group B), and four cell lines had low enzyme activity without, or with, D3T (group C). Two cell lines in group A and two cell lines in group B had a C to T polymorphism at base 609 in the NQO(1), DT-diaphorase gene, in one allele, while all four cell lines in group C were homozygous mutants. The base 609 mutant NQO(1) gene produces a protein with little enzyme activity. In group A, D3T increased NQO(1) mRNA and wild-type protein, and also increased mutant protein in the two heterozygous cell lines. In group B, the inducer slightly increased NQO(1) mRNA, did not increase the wild-type protein, but did increase the mutant protein in the two heterozygous cell lines. In group C, D3T increased NQO(1) mRNA as well as its mutant enzyme product. Transfection of the mutant NQO(1) gene into cells with two wild-type alleles did not alter DT-diaphorase activity. The results suggest that the lack of induction of DT-diaphorase activity is transcriptional in nature, that basal and induced expression of DT-diaphorase are regulated independently, and that mutant NQO(1) does not act as a dominant-negative to suppress DT-diaphorase activity.

Enhanced cytotoxicity of mitomycin C in human tumour cells with inducers of DT-diaphorase.

DT-diaphorase is a two-electron reducing enzyme that activates the bioreductive anti-tumour agent, mitomycin C (MMC). Cell lines having elevated levels of DT-diaphorase are generally more sensitive to MMC. We have shown that DT-diaphorase can be induced in human tumour cells by a number of compounds, including 1,2-dithiole-3-thione. In this study, we investigated whether induction of DT-diaphorase could enhance the cytotoxic activity of MMC in six human tumour cell lines representing four tumour types. DT-diaphorase was induced by many dietary inducers, including propyl gallate, dimethyl maleate, dimethyl fumarate and sulforaphane. The cytotoxicity of MMC was significantly increased in four tumour lines with the increase ranging from 1.4- to threefold. In contrast, MMC activity was not increased in SK-MEL-28 human melanoma cells and AGS human gastric cancer cells, cell lines that have high base levels of DT-diaphorase activity. Toxicity to normal human marrow cells was increased by 50% when MMC was combined with 1,2-dithiole-3-thione, but this increase was small in comparison with the threefold increase in cytotoxicity to tumour cells. This study demonstrates that induction of DT-diaphorase can increase the cytotoxic activity of MMC in human tumour cell lines, and suggests that it may be possible to use non-toxic inducers of DT-diaphorase to enhance the efficacy of bioreductive anti-tumour agents.

Induction of DT-diaphorase by 1,2-dithiole-3-thiones in human tumour and normal cells and effect on anti-tumour activity of bioreductive agents.

DT-diaphorase is a two-electron-reducing enzyme that is an important activator of bioreductive anti-tumour agents, such as mitomycin C (MMC) and EO9, and is inducible by many compounds, including 1,2-dithiole-3-thiones (D3Ts). We showed previously that D3T selectively increased DT-diaphorase activity in mouse lymphoma cells compared with normal mouse marrow cells, and also increased MMC or EO9 cytotoxic activity in the lymphoma cells with only minor effects in the marrow cells. In this study, we found that D3T significantly increased DT-diaphorase activity in 28 of 38 human tumour cell lines representing ten tissue types with no obvious relationships between the tumour type, or the base level of DT-diaphorase activity, and the ability of D3T to increase the enzyme activity. Induction of DT-diaphorase activity in human tumour cell lines by 12 D3T analogues varied markedly with the D3T structure. D3T also increased DT-diaphorase activity in normal human bone marrow and kidney cells but the increases were small in these cells. In addition, D3T increased the level of enzyme activity in normal human lung cells. Pretreatment of human tumour cells with D3T analogues significantly increased the cytotoxic activity of MMC or EO9 in these cells, and the level of enhancement of anti-tumour activity paralleled the level of DT-diaphorase induction. In contrast, D3T did not effect the toxicity of EO9 in normal kidney cells. These results demonstrate that D3T analogues can increase DT-diaphorase activity in a wide variety of human tumour cells and that this effect can enhance the anti-tumour activity of the bioreductive agents MMC and EO9.

Induction of DT-diaphorase in cancer chemoprevention and chemotherapy.

DT-diaphorase (EC 1.6.99.2) is a flavoprotein that catalyses two-electron reduction of quinones, quinone imines, and nitrogen oxides. It is a Phase II detoxifying enzyme that can detoxify chemically reactive metabolites, and may be important in an early cellular defense against tumorigenesis. DT-diaphorase is also an activating enzyme for bioreductive antitumor agents like mitomycin C (MMC) and EO9. DT-diaphorase is induced in many tissues by a wide variety of compounds including dithiolethiones and isothiocyanates. Dithiolethiones are chemoprotective agents against a variety of chemical carcinogens in animal models, and the dithiolethione analogue, oltipraz, is currently in Phase I and Phase II clinical chemoprevention trials. Similarly, the isothiocyanate derivative, sulforaphane, blocks the formation of carcinogen-induced mammary tumors in rats. The low toxicity of these inducers of DT-diaphorase makes them suitable for use as chemopreventive agents in high-risk individuals. Cells with elevated DT-diaphorase levels are generally more sensitive to bioreductive antitumor agents. Thus, we suggested that the antitumor efficacy of bioreductive agents can be enhanced by selective induction of DT-diaphorase in tumor cells compared with normal cells. We showed that 1,2-dithiole-3-thione (D3T) can increase the level of DT-diaphorase activity and the cytotoxic activity of bioreductive agents in mouse lymphoma cells without increasing these activities in normal mouse marrow cells. D3T also increased DT-diaphorase activity in 24 of 33 human tumor cell lines representing nine tissue types with no obvious relationships between the tumor type, or the base level of DT-diaphorase activity, and the ability to increase enzyme activity. A series of dithiolethione analogues and dietary components were also shown to be good inducers of DT-diaphorase in human tumor cells. D3T increased DT-diaphorase activity in normal human bone marrow and kidney cells but the increases were small in these cells. Combination treatment with D3T and EO9 increased cell kill in HL-60 human leukemia cells compared with EO9 alone, but had no effect on EO9 toxicity in normal human kidney cells. Similarly, D3T increased tumor cell kill by EO9 in H661 human lung cancer cells and by MMC in T47D human breast cancer cells. Thus, inducers of DT-diaphorase may play an important role in cancer chemoprevention programs and may also be useful in enhancing the antitumor efficacy of bioreductive agents.

Induction of DT-diaphorase by 1,2-dithiole-3-thione and increase of antitumour activity of bioreductive agents.

Bioreductive antitumour agents are an important new class of anticancer drugs that require activation by reduction. The two-electron reducing enzyme, DT-diaphorase, has been shown to be an important activating enzyme for the bioreductive agents, mitomycin C (MMC) and EO9. Incubation of L5178Y murine lymphoma cells in vitro with 1,2-dithiole-3-thione (D3T) increased the level of DT-diaphorase activity in these cells 22-fold. In contrast, D3T had no effect on the DT-diaphorase level in normal mouse bone marrow cells. Combination therapy with D3T and MMC or EO9, produced a 2- or 7-fold enhancement, respectively, of the cytotoxic activity of these antitumour agents in L5178Y cells. By comparison, D3T did not enhance the activity of MMC in marrow cells and produced only a small increase in EO9 cytotoxicity in these cells. The DT-diaphorase inhibitor, dicoumarol, inhibited the effect of D3T on the antitumour activity of the bioreductive agents, supporting the proposal that the enhanced anticancer activity was due to the elevated enzyme level. These findings suggest that D3T, or other inducers of DT-diaphorase, could be used to enhance the antitumour efficacy of bioreductive antitumour agents.

Induction of DT-diaphorase by doxorubicin and combination therapy with mitomycin C in vitro.

Mitomycin C (MMC) is a bioreductive antitumor agent that is activated by NADPH:cytochrome P450 reductase (EC 1.6.2.4) and NAD(P)H:(quinone acceptor) oxidoreductase (EC 1.6.99.2) (DT-diaphorase). DT-diaphorase is a two-electron reducing enzyme that is induced by a variety of chemicals, including quinones. Doxorubicin (DOX) is an anthraquinone antitumor agent that has been used clinically with MMC for combination chemotherapy in breast cancer. In this study, we investigated whether DOX could selectively induce DT-diaphorase in tumor cells and whether combining this agent with MMC in an appropriate schedule could produce synergistic antitumor activity. Treatment of EMT6 murine mammary tumor cells with DOX resulted in a 40% increase in DT-diaphorase activity in these cells, but had no effect on this enzyme in murine bone marrow cells. Combination therapy with DOX and MMC produced a 1.4-fold level of synergistic cell kill in the tumor cells, but a similar level of synergy was also observed in normal bone marrow cells. Thus, DOX can selectively induce elevated levels of DT-diaphorase in tumor cells; however, the synergy observed by combining this agent with MMC appears to be unrelated to the induction of DT-diaphorase.

Activity of 3'-(3-cyano-4-morpholinyl)-3'-deaminoadriamycin in sensitive and resistant L5178Y lymphoblasts in vitro.

An L5178Y murine lymphoblast cell line resistant to 3'-(3-cyano-4-morpholinyl)-3'-deaminoadriamycin (MRA-CN), L5178Y/MRA-CN, was isolated and characterized. L5178Y/MRA-CN cells were 9.6-fold resistant to MRA-CN compared with parental cells. The resistant cell line also displayed 2-fold resistance to 3'-(4-morpholinyl)-3'-deaminoadriamycin but was not cross-resistant to Adriamycin or chlorambucil. Uptake of MRA-CN was slightly reduced in the resistant cells compared to sensitive cells, but the distribution of the drug within the cells was unchanged. DNA interstrand cross-linking by MRA-CN was not significantly different in the sensitive and resistant cell lines, but MRA-CN was slightly less effective in inhibiting both DNA and RNA synthesis in L5178Y/MRA-CN cells compared with parental cells. NADPH cytochrome P-450 reductase activity was increased in L5178Y/MRA-CN cells compared to parental cells, while the activity of DT-diaphorase was decreased in the resistant cells. The levels of glutathione and glutathione S-transferase activity were increased in the resistant cells compared to sensitive cells; however, pretreatment of L5178Y/MRA-CN cells with buthionine sulfoximine to reduce the glutathione level did not reverse the resistance of these cells to MRA-CN. MRA-CN induced DNA fragmentation that was characteristic of apoptosis in both L5178Y and L5178Y/MRA-CN cells at equitoxic drug concentrations. However, apoptosis occurred more rapidly in L5178Y/MRA-CN cells compared with parental cells. Thus, MRA-CN induces apoptosis in L5178Y cells, and this effect may be important for the anti-tumor activity of this agent. In contrast, DNA interstrand cross-linking does not appear to be the primary mechanism responsible for the cytotoxicity of MRA-CN in these cells.

Role of NAD(P)H:(quinone acceptor) oxidoreductase (DT-diaphorase) in activation of mitomycin C under acidic conditions.

The quinone antitumor agent mitomycin C is preferentially toxic to some cells under hypoxic and acidic conditions. The two-electron reducing enzyme DT-diaphorase may be a major contributor to mitomycin C activation under aerobic conditions, but its role in drug activation under hypoxic and acidic conditions is unclear. In this study, we observed that mitomycin C produced increased DNA cross-linking and cytotoxicity in Chinese hamster ovary cells at pH 6.6, compared with pH 7.2, under aerobic conditions, but drug activity was similar at these pH values under hypoxic conditions. The DT-diaphorase inhibitor dicoumarol completely inhibited the enhanced activity of mitomycin C at acidic pH under aerobic conditions but had no effect on DNA cross-linking or cytotoxicity under hypoxic conditions. These finding suggest that the enhanced activity of mitomycin C at acidic pH, in air, is due to increased drug activation by DT-diaphorase. However, the role of DT-diaphorase in activating mitomycin C under hypoxic conditions appears to be limited, even at acidic pH.

Role of NAD(P)H:(quinone acceptor) oxidoreductase (DT-diaphorase) in activation of mitomycin C under hypoxia.

The role of the two-electron reducing enzyme DT-diaphorase in the activation of mitomycin C under hypoxic conditions was investigated. Mitomycin C activity was compared in L5178Y murine lymphoblasts, which have low levels of DT-diaphorase activity, and L5178Y/HBM10 cells, which have elevated levels of enzyme activity. The cytotoxic and DNA cross-linking activities of mitomycin C were greater in L5178Y/HBM10 cells than in L5178Y cells. In L5178Y/HBM10 cells, dicoumarol, an inhibitor of DT-diaphorase, decreased cell kill and DNA cross-linking by mitomycin C in air but had no significant effect on these activities under hypoxia. By comparison, in L5178Y cells, dicoumarol had no effect on drug activity under either aerobic or hypoxic conditions. A model for the activation of mitomycin C by both one-electron and two-electron reduction is proposed. Our findings suggest that two-electron reduction by DT-diaphorase has only a limited role in the activation of mitomycin C under hypoxic conditions, although this enzyme appears to be an important contributor to drug activation under aerobic conditions.

Mechanisms for the modulation of alkylating activity by the quinone group in quinone alkylating agents.

Previous studies have demonstrated that the quinone group may play an important role in modulating the alkylating activity of quinone alkylating agents. Introduction of a quinone moiety markedly increased the alkylating activity and cytotoxic activity of the model quinone alkylating agents benzoquinone mustard and benzoquinone dimustard. However, the cytotoxic and DNA-damaging activity of benzoquinone mustard was considerably greater than that of benzoquinone dimustard. In this study, we have investigated the role of the quinone group as a modulator of alkylating activity in these antitumor agents, using extracellular assays to eliminate differences due to cellular drug uptake and metabolism. Evidence was obtained that the alkylating activities of both benzoquinone mustard and benzoquinone dimustard were enhanced by reduction of the quinone group. In addition, when these agents were reduced, they displayed equal alkylating activity. This finding suggests that the difference in the activity of these agents in cells is not due to intrinsic differences in alkylating activities of the activated forms of these agents. Electrochemical studies revealed that benzoquinone dimustard has a lower redox potential than benzoquinone mustard and, thus, is less easily reduced. Inactivation and spectroscopic studies suggested that a major reason for the differences in activity between benzoquinone mustard and benzoquinone dimustard may be the rapid inactivation of the dimustard before its reduction. This effect may be enhanced by the lower redox potential of benzoquinone dimustard, compared with benzoquinone mustard. These findings support the hypothesis that the quinone group can modulate the alkylating activity of quinone alkylating agents; however, the mechanisms by which this modulation occurs may vary for different antitumor agents.

Activity of quinone alkylating agents in quinone-resistant cells.

The role of the quinone group in the antitumor activity of quinone alkylating agents, such as mitomycin C and 2,5-diaziridinyl-3,5-bis(carboethoxyamino)-1,4-benzoquinone, is still uncertain. The quinone group may contribute to antitumor activity by inducing DNA strand breaks through the formation of free radicals and/or by influencing the alkylating activity of the quinone alkylators. The cytotoxic activity and DNA damage produced by the model quinone alkylating agents, benzoquinone mustard and benzoquinone dimustard, were compared in L5178Y murine lymphoblasts sensitive and resistant to the model quinone antitumor agent, hydrolyzed benzoquinone mustard. The resistant cell lines, L5178Y/HBM2 and L5178Y/HBM10, have increased concentrations of glutathione and elevated catalase, superoxide dismutase, glutathione S-transferase, and DT-diaphorase activity. L5178Y/HBM2 and L5178Y/HBM10 cells were 7.4- and 8.5-fold less sensitive to benzoquinone mustard and 1.7- and 4.3-fold less sensitive to benzoquinone dimustard, respectively, compared with sensitive cells, but showed no resistance to the non-quinone alkylating agent, aniline mustard. The formation of DNA double strand breaks by benzoquinone mustard was reduced by 2- and 8-fold in L5178Y/HBM2 and L5178Y/HBM10 cells, respectively, while double strand break formation by benzoquinone dimustard was reduced only in the L5178Y/HBM10 cells. The number of DNA-DNA cross-links produced by benzoquinone mustard was 3- and 6-fold lower, and the number produced by benzoquinone dimustard was 35% and 2-fold lower in L5178Y/HBM2 and L5178Y/HBM10 cells, respectively, compared with L5178Y parental cells. In contrast, cross-linking by aniline mustard was unchanged in sensitive and resistant cells. Dicoumarol, an inhibitor of DT-diaphorase, increased the cytotoxic activity of both benzoquinone mustard and benzoquinone dimustard in L5178Y/HBM10 cells. This study provides evidence that elevated DT-diaphorase activity in the resistant cells contributes to resistance to benzoquinone mustard and benzoquinone dimustard, possibly by decreasing the formation of the semiquinone intermediates of these agents. The altered reduction of the quinone groups in the resistant cells may be responsible for the decreased DNA-DNA cross-linking and lowered induction of DNA strand breaks by the quinone alkylating agents. These findings demonstrate that the quinone group can modulate the activity of quinone alkylating agents. The study also suggests that the semiquinone intermediates of benzoquinone mustard and benzoquinone dimustard may be the active alkylating species of these two agents.

Increased sensitivity of quinone resistant cells to mitomycin C.

L5178Y cells resistant to the model quinone antitumor agent, hydrolyzed benzoquinone mustard, were four-fold more sensitive to mitomycin C compared to parental cells. Mitomycin C also produced increased DNA-DNA crosslinking in these cells compared to parental L5178Y cells, but did not induce DNA double strand breaks in either cell line. The resistant cells have a 24-fold increased level of DT-diaphorase activity, an enzyme that produces two electron reduction of quinone groups. Dicoumarol, an inhibitor of DT-diaphorase, significantly inhibited crosslinking and cytotoxicity by mitomycin C in the quinone resistant cells. These findings suggest that DNA-DNA cross-linking may be a major contributor to mitomycin C cytotoxic activity in L5178Y cells, and that the hydroquinone of mitomycin C may play a major role in the crosslinking activity of this agent.

Characterization of L5178Y murine lymphoblasts resistant to quinone antitumor agents.

The exact contribution of the quinone group to the activity of quinone antitumor agents remains uncertain. Two L5178Y murine lymphoblastic cell lines resistant to the model quinone antitumor agent, hydrolyzed benzoquinone mustard, and one partial-revertant cell line were isolated and characterized. The antitumor activity of hydrolyzed benzoquinone mustard has been shown previously to be due to its ability to induce free radical mediated DNA strand breaks. Resistant cells were obtained by growing a cloned L5178Y parental cell line in media containing increasing concentrations of hydrolyzed benzoquinone mustard. L5178Y/HBM2 cells were selected from L5178Y cells growing in media containing 0.2 mM drug, while L5178Y/HBM10 cells were selected from cells growing in media containing 1.0 mM drug. The L5178Y/HBMR cells were obtained by growing L5178Y/HBM10 cells in media without hydrolyzed benzoquinone mustard. The resistant cell lines, L5178Y/HBM2 and L5178Y/HBM10, were 2.5- and 6-fold less sensitive, respectively, to hydrolyzed benzoquinone mustard compared to parental cells, and this was accompanied by a decrease in the formation of DNA single and double strand breaks by this drug. The partial-revertant cell line, L5178Y/HBMR was 2.9-fold less sensitive to hydrolyzed benzoquinone mustard compared to parental cells. Drug uptake appeared to be lower in the resistant cells compared to parental cells. The resistant cells had a slightly elevated level of superoxide dismutase activity compared to parental cells, but there was no increase in the mRNA for superoxide dismutase nor any amplification of the gene for this enzyme. Intracellular catalase activities of the L5178Y/HBM2 and L5178Y/HBM10 cells were elevated by 1.25- and 2.6-fold, respectively, and the increased enzyme activity in the L5178Y/HBM10 cells appeared to result from a 3.6-fold increase in mRNA for this enzyme. Glutathione peroxidase activity was slightly elevated in L5178Y/HBM2 cells, but was unchanged in the other resistant cells. The L5178Y/HBM2 and L5178Y/HBM10 cells showed increased concentrations of glutathione and elevated levels of glutathione transferase activity. The resistant cell lines also had DT-diaphorase activity that was 3- and 24-fold higher in L5178Y/HBM2 and L5178Y/HBM10 cells, respectively, compared to sensitive cells. However, cytochrome P-450 reductase activity and the ratio of reduced to oxidized pyridine nucleotides was unchanged in the resistant cell lines. The partial-revertant cell line, L5178Y/HBMR, showed approximately the same level of resistance to hydrolyzed benzoquinone mustard as the L5178Y/HBM2 cells.(ABSTRACT TRUNCATED AT 400 WORDS)