International Journal of Research and Review www.ijrrjournal.com E-ISSN: 2349-9788; P-ISSN: 2454-2237

Original Research Article

Impact of Perceived on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal

Dr. Arunima Chaudhuri1, Dr. Debdut Banerjee2

1Associate Professor, Department of Physiology, Rampurhat Government Medical College and Hospital (Affiliated to West Bengal University of Health Sciences), Rampurhat, West Bengal, India. 2Assistant Professor, Gynaecology and Obstetrics, Burdwan Medical College and Hospital, West Bengal, India.

Corresponding Author: Dr. Debdut Banerjee

ABSTRACT

Background: Psychoneuroimmunology is a scientific field dealing with the relationships between the mind, the brain and the immune system and focuses on how these relationships affect health and susceptibility to . Aims: To study impact of perceived stress on white blood cell count, erythrocyte sedimentation rate and lipid profile among first MBBS students in a medical college of West Bengal. Materials and methods: This cross‑sectional study was conducted in a medical college of eastern India. Approval from the institutional ethics committee and informed consent of the subjects was taken before conduction of this pilot project. On the first appointment, histories of the subjects were carefully recorded and general physical examination was done. BMI, Pulse, Blood Pressure were recorded. One hundred and twenty‑one subjects were finally selected. The stress level in the subjects was assessed according to the presumptive life event stress scale (PSLES). Accordingly, they were categorized into two groups: 41–200 less/moderate stress; more than 200 severe stress. The perceived stress scale (PSS) of Cohen et al. was used for assessing perceived stress levels. Fasting blood sample were drawn for analysis of lipid profile, ESR and total count of white blood cells (WBC), Hb% were estimated. Statistical analysis: Data were analyzed using software SPSS version16; Unpaired t test was used. Results: One hundred and twenty-one subjects participated in the present study. Seventy- five subjects were male and forty-six were female. All subjects were on non-vegetarian diet. Sixty-six subjects had PSLES scores above 200 and fifty-five subjects had scores less than 200. There was no significant difference in age between the two groups: 18.4±1.02 vs. 18.8±1.2; P value 0.2. Results showed significant difference in WBC count, ESR, Hb%, Total Cholesterol, Triglyceride, LDL, HDL level, PSLES and PSS scores, but no significant difference in VDL level between the two groups. There was significant difference in BMI, Pulse and blood pressure between the two groups. Conclusions: The prevalence of stress was found to be high during the initial years of study among MBBS students. Physical problems were associated with high stress levels. Results of the present study showed significantly higher WBC count, ESR, Hb%, Total Cholesterol, Triglyceride, LDL, PSLES and PSS scores, BMI, Pulse and blood pressure values in subjects with higher stress scores and decrease in values of HDL. All these factors may increase the risk of cardiovascular . Preventive mental health services, therefore, should be made an integral part of routine clinical services for medical students, especially in the initial academic years, to prevent such occurrence.

International Journal of Research & Review (www.ijrrjournal.com) 220 Vol.5; Issue: 12; December 2018

Keywords: Perceived stress, WBC count, ESR and lipid profile.

INTRODUCTION marital unhappiness, and burden of Medical education is perceived as caregiving. Although trigger being stressful, and a high level of stress events, it is less clear that stress “causes” may have a negative effect on cognitive the events. [6-7] functioning and health of students in a Cardiovascular diseases claim more medical school. The prevalence of stress has lives worldwide than any other. been found to be higher during the initial Etiologically, the dominant trajectory three years of study. [1-6] The seven leading involves atherosclerosis, a chronic causes of death in the general population inflammatory process of lipid-rich lesion are: diseases of the heart, cancer, growth in the vascular wall that can cause intracranial lesions of vascular origin life-threatening myocardial infarction (MI). (cerebrovascular), accidents, nephritis, Leukocytes - white blood cells - are pneumonia and influenza, and tuberculosis. important participants at the various stages These are not the same as the seven leading of cardiovascular disease progression and causes of death among physicians. [1] For complication. Atherosclerosis is the example, arteriosclerosis, diabetes and pathology that leads to myocardial cirrhosis of the liver each caused more infarction and stroke. Atherosclerosis is a deaths among physicians. Globally, about chronic inflammatory disease driven by 17 million people die of cardiovascular lipids, specifically low density lipoproteins diseases (CVDs) every year and a (LDL) and leukocytes. Lifestyle, age, substantial number of these deaths are hereditary factors, and co-morbidities attributed to major risk factors namely disturb immune, digestive, endocrine, unhealthy diet, physical inactivity, tobacco circulatory, and nervous systems, thereby consumption, alcohol consumption and altering immune function, metabolism, and stress. Doctors and nurses often have a many other processes, while eliciting sedentary lifestyle. [6-7] inflammation, hypercholesterolemia, and A study BY Hedge SKB et al [7] was hypertension. Atherosclerosis develops and aimed at assessing the lifestyle-associated causes myocardial infarction or stroke when risk for CVDs among doctors and nurses in many things go wrong in many different a medical college hospital. A cross-sectional ways. [8] study was conducted among 250 doctors The natural progression of and nurses, selected using a stratified atherosclerosis in the human involves the random sampling, working at a medical acquisition of specific features in the college hospital in Tamil Nadu. It was found growing lesion. A key initiating process of that 31.2% of all study subjects and 49.2% atherosclerosis is the intimal retention of of doctors were at high general risk for apolipoprotein (apo) B-containing CVDs; 30.4% of all study subjects and lipoproteins in regions of disturbed blood 42.1% of doctors were at high physical flow and low shear stress. The existence of activity-related risk for CVDs; 14.4% of all small pools of extracellular lipids in the study subjects and 19.8% of all doctors were intima is a feature of a preatheroma, at high dietary pattern-related risk for whereas an easily discernible core of CVDs. Doctors were found to be at a higher extracellular lipid marks an atheroma. risk for CVDs as compared to nurses as well Increasingly complicated lesions are defined as the general population. [7] by fibrous thickening; the appearance of There is an enormous amount of fissures, hematoma, and thrombi; and literature on psychological stress and calcification. Problems occur if a lesion cardiovascular disease. Studies of chronic interferes with tissue oxygenation when stressors are discussed in terms of job stress, either the lesion’s size reduces blood flow

International Journal of Research & Review (www.ijrrjournal.com) 221 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal or the lesion ruptures and occludes the immunity. Chronic stressors were associated vessel altogether. Of the two, lesion rupture with suppression of both cellular and is far more dangerous. Myocardial humoral measures. infarction and stroke are sudden events that Sympathetic fibers descend from the result from occlusion of vessels that brain into both primary (bone marrow and oxygenate the heart and brain, respectively. thymus) and secondary (spleen and lymph [8] nodes) lymphoid tissues. These fibers can Macrophages are most numerous release a wide variety of substances that among leukocytes in any type of lesion and, influence immune responses by binding to with the possible exception of smooth receptors on white blood cells. Though all muscle cells, the most prominent cellular lymphocytes have adrenergic receptors, contributors to the lesion’s physical bulk. In differential density and sensitivity of response to intimal lipid accumulation, adrenergic receptors on lymphocytes may disturbed blood flow, low shear stress, and affect responsiveness to stress among cell other stimuli, endothelial cells permit subsets. The hypothalamic–pituitary– monocytes - major precursors of adrenal axis, the sympathetic–adrenal– macrophages - passage across the medullary axis, and the hypothalamic– endothelium. Newly-infiltrated monocyte- pituitary–ovarian axis secrete the adrenal derived macrophages recognize and ingest hormones epinephrine, norepinephrine, and lipids that have accrued in the intima as a cortisol; the pituitary hormones prolactin consequence of hypercholesterolemia. and growth hormone; and the brain peptides Macrophages are specialized phagocytes melatonin, β-endorphin, and enkephalin. that rely on different strategies to sense, These substances bind to specific receptors internalize, and process the diverse lipid on white blood cells and have diverse moieties they encounter. Lipoprotein regulatory effects on their distribution and recognition and consequent ingestion function. People’s efforts to manage the morphs macrophages into foam cells, many demands of stressful experience sometimes of which eventually die and contribute to a lead them to engage in behaviors-such as large lipid core, a characteristic of lesions alcohol use or changes in sleeping patterns- most vulnerable to rupture. Leukocytes may that also could modify immune system fuel an inflammatory cycle, but they also, in processes. Thus, behavior represents a some incarnations, quench it. In response to potentially important pathway linking stress hypercholesterolemia, the bone marrow and with the immune system. [9] spleen overproduce Ly-6Chigh monocytes Chronic stress might shift the that enter the circulation, contribute to balance of the immune response. Chronic excessive monocytosis, preferentially stress elicits simultaneous enhancement and accumulate in lesions, and differentiate to suppression of the immune response by macrophages. [8] altering patterns of cytokine secretion. Th1 A report by Segerstrom SC et al [9] cytokines, which activate cellular immunity meta-analyzed more than 300 empirical to provide defense against many kinds of articles describing a relationship between and some kinds of neoplastic psychological stress and parameters of the disease, are suppressed. This suppression immune system in human participants. has permissive effects on production of Th2 Acute stressors were found to be associated cytokines, which activate humoral immunity with potentially adaptive upregulation of and exacerbate allergy and many kinds of some parameters of natural immunity and autoimmune disease. This shift can occur downregulation of some functions of via the effects of stress hormones such as specific immunity. Brief naturalistic cortisol. Th1-to-Th2 shift changes the stressors tended to suppress cellular balance of the immune response without immunity while preserving humoral necessarily changing the overall level of

International Journal of Research & Review (www.ijrrjournal.com) 222 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal activation or function within the system. on immune parameters were apparent in Because a diminished Th1-mediated cellular only women who showed concomitant and immune response could increase substantial sympathetic nervous system vulnerability to infectious and neoplastic activation and after statistical adjustment for disease, and an enhanced Th-2 mediated changes in plasma volume. Nineteen women humoral immune response could increase in the follicular stage of their menstrual vulnerability to autoimmune and allergic cycles were assessed for immunological diseases, this cytokine shift model also is responsiveness to a series of three 3-minute able to reconcile patterns of stress-related psychological tasks, which reliably elicit immune change with patterns of stress- cardiovascular and neuroendocrine stress related disease outcomes. [9] responses. Women were classified as high or low sympathetic reactors based on their Relationships between work-related cardiovascular and neuroendocrine psychological and physical stress responses responses to one of the three tasks, a public and counts of white blood cells (WBCs), speaking task. The stress-induced decreases neutrophils, and lymphocytes were in CD4+ percentage and increases in natural investigated in 101 daytime workers by killer cell number and cytolytic activity Nishitani N et al. [10] Counts of WBCs and were only apparent among the high reactors. neutrophils were positively associated with Further analysis adjusting for alterations in smoking and inversely correlated with high plasma volume changes showed that the density lipoprotein (HDL)-cholesterol increase in NK cell number remained. levels. General fatigue score as measured by Stress-induced proliferative responses to the profile of mood state was positively pokeweed mitogen and phytohemagglutinin correlated with WBC and neutrophil counts were not more apparent among high whereas lymphocyte counts was not reactors. These results are consistent with significantly associated with fatigue score. the hypothesis that the sympathetic nervous Multiple regression analysis showed that system plays a direct role in modulating the WBC count was significantly related to short term response to stress of some indices general fatigue, age, and HDL-cholesterol of the immune system in women. levels. Neutrophil count was significantly Psychological stress suppresses related to HDL-cholesterol levels and various parameters of immune functions and fatigue score. Among various psychological consequently can cause diseases. Various stress response variables, general fatigue studies suggested that the nature of may be a key determinant of low-grade (acute or chronic) may have differential inflammation as represented by increases of impact upon the immune functioning, with WBC and neutrophil counts. Job stress was brief acute stress enhancing some found to be related to a dampened innate parameters of immunity whereas chronic immune defense that may change the pattern stress adversely affecting almost all of cytokine production, leading to an parameters of immune functions. Stress and increase of inflammatory response which immune functions are mediated by the could influence WBC count as well. hypothalamic-pituitary-adrenal (HPA) axis Similarly, IL-6 levels, an important marker and the autonomic (sympathetic and of chronic low-grade inflammation, have parasympathetic) nervous system. In been reported to increase by sleep disorders addition, there is a possibility of behavioral and fatigue. Fatigue may promote pathways (such as alcohol intake, sleep inflammatory response on one hand and disturbances) through which stress affects suppression of cellular immune response on immune functions. [12] the other. [10] In response to a stressor, Matthews KA et al [11] in their study physiological changes are set into motion to evaluated whether the effects of acute stress help an individual cope with the stressor.

International Journal of Research & Review (www.ijrrjournal.com) 223 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal

However, chronic activation of these stress interpreted using Franceschi and Campisi’s responses, which include the hypothalamic- (2014) biphasic model showing that acute pituitary-adrenal axis and the sympathetic- stress can decrease inflammation, although adrenal-medullary axis, results in chronic chronic stress can increase. [14] production of glucocorticoid hormones and The effect of a 75-hour vigil on the catecholamines. Glucocorticoid receptors erythrocyte sedimentation rate (ESR) was expressed on a variety of immune cells bind studied in two experiments with 63 healthy cortisol and interfere with the function of male volunteers in a study. The ESR was NF-kB, which regulates the activity of increased at the end of the vigil compared cytokine-producing immune cells. with pre-exposure values. The increases did Adrenergic receptors bind epinephrine and not correlate significantly with concomitant norepinephrine and activate the cAMP changes in serum triglycerides, free fatty response element binding protein, inducing acids, cholesterol or gamma globulins, the transcription of genes encoding for a except for a significant, negative correlation variety of cytokines. The changes in gene with cholesterol changes in one of the two expression mediated by glucocorticoid studies. Although the mechanism for the hormones and catecholamines can increases in ESR in response to stressor dysregulate immune function. The exposure remains unclear, it is concluded magnitude of stress-associated immune that when using the ESR in clinical practice, dysregulation is large enough to have health allowance should be made for situational implications. [13] factors such as the patient having Inflammation is central to the aging experienced some stressful days and process, and stress may play a key role in sleepless nights. [15] moderating inflammation factors, such as Thus the present study was IL-6 or CRP. While erythrocyte conducted to assess impact of perceived sedimentation rate (ESR) is widely used as a stress on white blood cell count, erythrocyte clinical marker of inflammatory processes, sedimentation rate and lipid profile among only a few cross-sectional studies have first MBBS students in a medical college of examined its relationship with psychosocial West Bengal so that early measures may be stress in humans, and these have shown taken in medical schools for improvement mixed results. Aldwin CM et al [14] used of the quality of life of medical longitudinal data from the VA Normative professionals. Aging Study (NAS), selecting 1,234 men (Mage in 1989 = 67.7, SD = 6.8, range = 53 MATERIALS AND METHODS - 82) who completed 1 to 5 biomedical This cross‑sectional study was conducted in examinations and the Health and Social a medical college of eastern India. Approval Behavior (HSB) surveys every three years from the institutional ethics committee and between 1989 and 2002 (total observations informed consent of the subjects was taken = 3,134, Mean individual observations = before conduction of this pilot project. 3.1, SD = 1.1). Multilevel modeling analysis Inclusion criteria: Medical students in the was used to examine within-and between- age group of 17-21 years of first MBBS person differences in ESR, stressful life batch were selected. events (SLEs), and hassles, controlling for Exclusion criteria: Subjects suffering from self-rated health, smoking, and alcohol chronic debilitating diseases such as cardiac consumption. Between-person analyses arrhythmias, hypertension, diabetes, showed that ESR increased with age and ischemic heart disease, retinopathy, smoking status. The within-person analyses nephropathy, or respiratory diseases, revealed that SLEs and self-rated health smokers, persons receiving any drug that negatively covaried with ESR, while may affect the autonomic reflexes were smoking still increased ESR. Results were excluded. Subjects on treatment from

International Journal of Research & Review (www.ijrrjournal.com) 224 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal psychiatry problem, pregnant women, profile, ESR and total count of white blood puerperal mothers, subjects on regular cells (WBC), Hb% were estimated. meditation and exercise regime were Increased sympathetic activity has excluded. Women on oral contraceptives been observed during the premenstrual were not included. phase and this was positively correlated On the first appointment, histories of with the stress levels in previous studies. [16- the subjects were carefully recorded and 18] To avoid stress effects of the general physical examination was done. premenstrual phase, we examined our BMI, Pulse, Blood Pressure were recorded. subjects during the postmenstrual phase. One hundred and twenty‑one subjects were Statistical analysis: Data were analyzed finally selected. Pre-test instructions were using software SPSS version16; probability given to avoid consumption of any drugs values (P Value) <0.05 were considered as that may alter the Cardio respiratory statistically significant and P Values <0.01 parameters 48 hours prior to the test. The were considered as statistically highly subjects were advised for a good restful significant. Unpaired t test was used. sleep and to fast at least for 12 hours after a light dinner at the night before the test day. RESULTS On the day of the test, no cigarette, nicotine, One hundred and twenty-one coffee, or drugs were permitted. subjects participated in the present study. Subjects were asked to tally a list of Seventy- five subjects were male and forty- 43 life events based on a relative score. The six were female. All subjects were on non- stress level in the subjects was assessed vegetarian diet. Sixty-six subjects had according to the presumptive life event PSLES scores above 200 and fifty-five stress scale (PSLES). [16-18] Accordingly, subjects had scores less than 200. There was they were categorized into two groups: 41– no significant difference in age between the 200 less/moderate stress; more than 200 two groups: 18.4±1.02 vs. 18.8±1.2; P value severe stress. 0.2. Results showed significant difference in The perceived stress scale (PSS) of WBC count, ESR, Hb%, Total Cholesterol, Cohen et al. the most widely used Triglyceride, LDL, HDL level, PSLES and psychological instrument for measuring the PSS scores, but no significant difference in perception of stress, was used for assessing VDL level between the two groups (Table1, stress levels. It is a measure of the degree to Figure 1-3). There was significant which situations in one’s life are appraised difference in BMI, Pulse and blood pressure to be stressful. Items were designed to find between the two groups (Table 2). how unpredictable, uncontrollable, and overloaded respondents find their lives. The scale also includes a number of direct queries about current levels of experienced stress. The questions in the PSS ask about feelings and thoughts during the last month. It comprises of 10 items, four of which are reverse‑scored, measured on a 5‑point scale from 0 to 4. PSS scores are obtained by reversing responses (e.g., 0 = 4, 1 = 3, 2 = 2, 3 = 1 and 4 = 0) to the four positively stated items (items 4, 5, 7, and 8) and then summing across all scale items. Total score Figure 1: Comparison of WBC count ranges from 0 to 40. [16-18] Fasting blood sample were drawn for analysis of lipid

International Journal of Research & Review (www.ijrrjournal.com) 225 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal

Figure 2: Comparison of ESR and Hemoglobin

Figure 3: Comparison of Lipid profile

Table 1: Shows comparison of different parameters of subjects with PSLES scores more than 200 and less than 200. Mean ± SD Parameters Subjects with PSLES scores more than 200 Subjects with PSLES scores less than 200 P value WBC count/mm3 8483.6± 1241.26 8142± 1146.94 0.046* ESR mm/hr 13.97± 2.34 12.97± 2.99 0.009** Hb gm/dl of blood 14.01±1.46 13.59±1.36 0.041* Cholesterol(mg/dl) 161.06± 20.6 155.85± 14.35 0.041* Triglyceride(mg/dl) 125.57± 25.2 116.17± 25.28 0.0098** LDL(mg/dl) 93.3± 15.83 86.62 ± 12.5 0.0012** HDL(mg/dl) 41.4± 5.35 46.54±2.3 <0.001** VLDL(mg/dl) 24.44±4.73 23.91±5.7 0.47 Perceived stress score 28.2±3.1 19.4±2.6 <0.001** PSLES score 311.9±26.2 162.8±25.5 <0.001** Results show significant difference in WBC count, ESR, Hb%, Total Cholesterol, Triglyceride, LDL, HDL level, PSLES and PSS scores, but no significant difference in VDL level. P-value <0.05* (significant) P-value <0.01** (highly significant)

Table- 2: The average values of BMI, Pulse, SBP, DBP ratio of the two groups are shown in the following table. Mean ± SD P- PARAMETERS SUBJECTS WITH PSLES SCORES MORE SUBJECTS WITH PSLES SCORES LESS VALUE THAN 200 THAN 200 BMI(kg/m2) 25.1±2.8 22.9±1.4 <0.001** PULSE (beats per 74.7 ± 4.5 72.7 ± 3.02 <0.001** minute) SBP(mm Hg) 117.7 ± 7.9 113.9 ± 5.9 <0.001** DBP(mm Hg) 80.04 ± 6.5 75.4 ± 5.4 <0.001** Results show significant difference in BMI, Pulse, SBP and DBP between these two groups. P-value <0.05 (*significant) P-value <0.01 (**highly significant)

DISCUSSION the nervous system. Long‑term effects of Psychoneuroimmunology (PNI) is a glucocorticoid hormones on leukocyte scientific field dealing with the relationships populations are seen in humans with chronic between the mind (psyche), the brain medical disorders; for example, Cushing's (neuro) and the immune system syndrome is a disorder characterized by (immunology). PNI focuses on how these chronically elevated levels of plasma relationships affect health and susceptibility cortisol and medical researchers have found to disease. Emotions affect our immune that patients with this disorder had system through neurotransmitters such as chronically elevated neutrophil counts and serotonin, dopamine, and nor-epinephrine, lower lymphocyte counts compared to which are injected into the blood and act on healthy individuals. Similarly, neutrophils white blood cells. Many cytokines (the are elevated and lymphocytes depressed in chemicals that white blood cells release to humans with psychological disorders such communicate with each other) also affect as depression and schizophrenia, which are

International Journal of Research & Review (www.ijrrjournal.com) 226 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal characterized by chronically elevated psychological stress that might be a risk plasma cortisol level. Elevated white blood factor for the pathogenesis of CVD. [24] cell (WBC) count has been reported to be an Secondary analysis of stress independent predictor of coronary heart hemoconcentration was performed on data disease and is associated with several from controls and subjects with mild to cardiovascular disease risk factors. Studies moderate MDD participating in an ongoing have reported that WBC count is a pharmacogenetic study of antidepressant convenient and useful marker to capture treatment response to desipramine or inflammatory responses because it is fluoxetine by Wong ML et al in 2008. [24] inexpensive compared to other Hematologic and hemorheologic measures inflammatory markers such as interleukin-6 of stress-hemoconcentration included blood (IL-6) and high-sensitivity C-reactive cell counts, hematocrit, hemoglobin, total protein (CRP). [19-21] In the present study we serum protein, and albumin, and whole found higher WBC count and ESR values in blood viscosity. Subjects with mild to subjects having higher PSS levels. Total moderate MDD had significantly increased Cholesterol, triglyceride, LDL were also hemorheologic measures of stress- significantly increased in these subjects and hemoconcentration and blood viscosity these factors are major contributors to when compared to controls; these measures development of cardiovascular diseases in were correlated with depression severity. future. Measures of stress-hemoconcentration A dose-response association exists improved significantly after 8 weeks of between exposure to work stress and the antidepressant treatment. Improvements in metabolic syndrome. Employees with white blood cell count, red blood cell chronic work stress have more than double measures and plasma volume were the odds of the syndrome than those without correlated with decreased severity of work stress, after other risk factors are taken depression. Secondary data analyses into account. Health professionals are an supported the concept that stress- important population subgroup, since they hemoconcentration, possibly caused by are committed to health promotion and decrements in plasma volume during prevention, or treatment of diseases, which psychological stress, is present in Mexican- affect not only their own health but also American subjects with mild to moderate communities, families and individuals with MDD at non-challenged baseline which they work. [22-23] In the present study conditions. It was also found that after we also observed that higher stress scores antidepressant treatment hemorheologic among MBBS students had a negative measures of stress-hemoconcentration were impact on their health profile. improved and were correlated with Cardiovascular disease (CVD) risk improvement of depressive symptoms. has been linked to several emotional and These findings suggest that antidepressant psychological factors, including stress and treatment may have a positive impact in depression. Mental stress can elicit acute CVD by ameliorating increased blood coronary events and is considered a risk viscosity. Physicians should be aware of the factor for CVD. Major depressive disorder potential impact of measures of (MDD) is an independent risk factor for hemoconcentration and consider the cardiovascular disease (CVD); the presence implications for cardiovascular risk in of MDD symptoms in patients with CVD is depressed patients. associated with a higher incidence of In the present study we also found cardiac complications following acute significantly higher Hb% in subjects with myocardial infarction (MI). Stress- higher stress scores. hemoconcentration, a result of To estimate the prevalence of depression and its relationship with disease

International Journal of Research & Review (www.ijrrjournal.com) 227 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal activity parameters in Egyptian patients <0.000). We found statistically significant with RA Mostafaa H et al [25] conducted a higher heart rate, diastolic blood pressure, study in 2013 on 170 patients with RA. The WHR, and PSS scores (22.05±5.02 vs. following values were assessed for each 19.25±4.21; P 0.003) in subjects having patient: erythrocyte sedimentation rate high PSLES scores. No significant effect of (ESR), C-reactive protein (CRP), stress scores was observed on systolic blood rheumatoid factor (RF), swollen and tender pressure. Examination results were joint counts (SJC and TJC), disease activity significantly worse in the highly stressed score 28 (DAS28), health assessment group (64.3±10.8 vs. 69.1±9.6; P 0.019) as questionnaire score (HAQ), visual analogue compared to subjects having moderate scale (VAS) of pain and hospital anxiety stress. [26] In the present study impact of and depression scale-depression subscale stress levels on WBC count ESR and Lipid (HADS-D). profile was analyzed. In the present study The prevalence of depression was only sixty- six subjects had PSLES score 15.29% (26 RA patients). In the depressed more than 200 and fifty- five had stress RA patients, positive significant correlations scores less than 200. Percentage of subjects were found between HADS-D score and having higher stress scores were age, disease duration, HAQ score, VAS, significantly more in the previous study as DAS28 score and CRP. However, no compared to the present one. In the present significant correlation was found between study significant difference in systolic blood HADS-D score and ESR, number of pressure was observed between the two swollen and tender joints. A high positive groups, while in the previous study there significant correlation was found between was no significant difference in systolic depression and CRP. Compared with non- blood pressure between the two groups. We depressed individuals, depressed patients did not study the effect of perceived stress have activated inflammatory pathways, on academic performance in the present including increased expression of study. These are the differences between the chemokines, adhesion molecules and two studies. cytokines. Patients with major depression From the above mentioned findings have increased serum and/or plasma of the present study it may be predicted that concentrations of CRP, IL-6 51, 52 and higher perceived stress levels among proinflammatory TNF-α. [25] medical students may increase the risk of The present study also observed developing cardiovascular diseases by increased WBC count and Higher ESR increasing WBC count, ESR levels, Total levels in subjects with higher stress scores. cholesterol, Triglyceride, LDL cholesterol We had conducted a study to levels and all these factors may contribute in observe effect of stress on academic development of atherosclerosis. performance and health profile in medical students in 2016. [26] One hundred and fifty Limitations and future scope: There are MBBS students in the age group of 18-20 several limitations to the present study. years under stress were chosen for the study. First, this was a cross-sectional study. Baseline anthropometric measurements Further longitudinal investigations are were done; body mass index and waist to needed to determine the impact of changes hip ratio (WHR) were calculated. Resting in WBCs and ESR as physical indicators pulse rate and blood pressure were due to a psychological stress response. In measured. The results of internal assessment this study, WBCs and ESR were examined, examinations conducted in this time period but the inflammatory mechanism is were recorded. A total of 30 subjects had complex. Further detailed investigation moderate PSLES scores (167.25±26.67); including cytokines and CRP levels may be 120 had high scores (373.86±149.21; P necessary to investigate the impact of stress

International Journal of Research & Review (www.ijrrjournal.com) 228 Vol.5; Issue: 12; December 2018 Arunima Chaudhuri et.al. Impact of Perceived Stress on White Blood Cell Count, Erythrocyte Sedimentation Rate and Lipid Profile among First MBBS Students in a Medical College of West Bengal among medical students on potential Lifestyle-associated risk for cardiovascular inflammatory processes. diseases among doctors and nurses working in a medical college hospital in Tamil Nadu, CONCLUSIONS India. J Family Med Prim Care. 2016 ; 5(2): The prevalence of stress was found 281–285. 8. Swirski FK, Nahrendorf M. Leukocyte to be high during the initial years of study behavior in atherosclerosis, myocardial among MBBS students. Physical problems infarction, and heart failure. Science. 2013; were associated with high stress levels. 339(6116): 161–166. Results of the present study showed 9. Segerstrom SC, Miller GE. Psychological significantly higher WBC count, ESR, Stress and the Human Immune System: A Hb%, Total Cholesterol, Triglyceride, LDL Meta-Analytic Study of 30 Years of Inquiry. cholesterol, PSLES and PSS scores, BMI, Psychol Bull. 2004; 130(4): 601–630. Pulse and blood pressure values in subjects 10. Nishitani N, Sakakibara H. Association of with higher stress scores and decrease in Psychological Stress Response of Fatigue values of HDL. Preventive mental health with White Blood Cell Count in Male services, therefore, should be made an Daytime Workers. Ind Health. 2014; 52(6): 531–534. integral part of routine clinical services for 11. Matthews KA, Caggiula AR, McAllister medical students, especially in the initial CG, Berga SL, Owens JF, Flory JD, Miller academic years, to prevent such occurrence. AL. Sympathetic reactivity to acute stress and immune response in women. Conflict of interest: Declared none. Psychosom Med. 1995;57(6):564-71. 12. Hussain D. Stress, Immunity, and Health: REFERENCES Research Findings and Implications. 1. Dimsdale JE. Psychological Stress and International Journal of Psychosocial Cardiovascular Disease. J Am Coll Cardiol. Rehabilitation. 2010; 15(1):94-100. 2008; 51(13): 1237–1246. 13. Padgett DA, Glaser R. How stress 2. AlKanhal AA, Mahmoud ES, influences the immune response. Trends in Ponnamperuma GG, Alfaris EA. Stress and immunology. 2004; 24(8): 444-48. Its Effects on Medical Students: A Cross- 14. Aldwin CM, Choun S, Nath R, Proulx J, sectional Study at a College of Medicine in Spiro A. Does erythrocyte sedimentation Saudi Arabia. J Health Popul Nutr. 2011; rate covary with stress? Longitudinal 29(5): 516–522. findings from the va normative aging study. 3. Tyseen R, Vaglum P, Gronvold NT, The Gerontologist. 2015; 55(2): 178–179. Ekeberg O. Factors in medical school that 15. Palmblad J, Karlsson CG, Levi L, Lidberg predict postgraduate mental health problems L. The erythrocyte sedimentation rate and in need of treatment. A nationwide and stress. Acta Med Scand. 1979;205(6):517- longitudinal study. Med Educ. 2001; 35: 20. 110–20. 16. Chaudhuri A, Ray M, Saldanha D, 4. Dahlin M, Joneborg N, Runeson B. Stress Bandopadhyay A. Effect of progressive and depression among medical students: a muscle relaxation in female health care cross-sectional study. Med Educ. 2005; 39: professionals. Ann Med Health Sci Res 594–604. 2014; 4:791‑5. 5. El-Gilany AH, Amr M, Hammad S. 17. Chaudhuri A, Roy M, Dasgupta S, Ghosh Perceived stress among male medical MK, Biswas A, Hazra S. Effect of students in Egypt and Saudi Arabia: effect progressive muscle relaxation on adverse of sociodemographic factors. Ann Saudi cardiovascular profile in women with Med. 2008; 28: 442–8. polycystic ovarian syndrome. J Basic Clin 6. Amr M, El-Gilany A, El-Sayed M, El- Reprod Sci 2014; 3:115‑20. Sheshtawy E. Study of stress among 18. Chaudhuri A, Ray M, Saldanha D, Sarkar medical students at Manssoura University. SK. Effects of progressive muscle relaxation Banha Med J. 2007; 37:25–31. on postmenopausal stress. J Sci Soc 2015; 7. Hegde SKB, Vijayakrishnan G ,Sasankh 42:62‑7. AK, Venkateswaran S, Parasuraman G.

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How to cite this article: Chaudhuri A, Banerjee D. Impact of perceived stress on white blood cell count, erythrocyte sedimentation rate and lipid profile among first MBBS students in a Medical College of West Bengal. International Journal of Research and Review. 2018; 5(12):220-230.

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International Journal of Research & Review (www.ijrrjournal.com) 230 Vol.5; Issue: 12; December 2018