Effect of background music on STress Responses Amongst Undergraduates and Surgeons performing Simulated Surgical tasks: A randomised cross-over interventional trial (The STRAUSS Study)

Effect of background music on STress Responses Amongst Undergraduates and Surgeons performing Simulated Surgical tasks: A randomised cross-over interventional trial (The STRAUSS Study) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effect of background music on STress Responses Amongst Undergraduates and Surgeons performing Simulated Surgical tasks: A randomised cross-over interventional trial (The STRAUSS Study) Anantha Narayanan, Manar Khashram, James P Fisher This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4225405/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 03 Jun, 2025 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract High stress may diminish a surgeon’s performance in the operating room (OR). Music is perceived to reduce stress in the OR, however the psycho-physiological effects of music on intra-operative stress in inexperienced and experienced operators is incompletely understood. The effect of music on the psychological (Six-Item State-Trait Anxiety Inventory [STAI-6] and Surgical Taskload Index [SURG-TLX]) and physiological responses (e.g., heart rate variability) was determined to a simulated surgical task (carotid patch-angioplasty) in 15 medical students (MS) and 12 vascular surgeons (VS) under stressing conditions in a randomised crossover design. Music did not affect the speed or accuracy of the simulated surgical stress task performance. While the surgical task increased SURG-TLX scores from baseline to control (D32 [ 22 – 42 ]; mean difference [95% confidence interval]) and to music (D30 [ 20 – 40 ]), and increased STAI-6 scores in both conditions, there was no difference between music and control. The surgical task also increased heart rate (peak D5.1bpm [3.0-7.1] vs. baseline p < 0.0001) and cardiac sympathetic nervous system activity (SNS index), and reduced parasympathetic (PNS index) nervous system activity, with the latter two exacerbated by music (SNS: 0.14 [0.004–0.27], p = 0.042; PNS: -0.11 [-0.22 - -0.008], p = 0.032). The more experienced group performed faster and more accurately than the inexperienced group, but there were no psychological or physiological differences in their responses to music. Despite previous research identifying generally positive surgeon perceptions of music on the intra-operative experience of stress, herein, background music failed to improve surgical task performance or attenuate subjective ratings of task load and anxiety, and physiological arousal. Biological sciences/Psychology/Human behaviour Biological sciences/Physiology/Circulation/Blood flow Health sciences/Diseases/Cardiovascular diseases/Vascular diseases/Carotid artery disease Health sciences/Health occupations Health sciences/Health care/Health services Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 INTRODUCTION It is common for surgeons to experience stress while they are performing surgery. 1 High levels of physiological and/or psychological stress have the potential to interfere with the expert execution of technical and non-technical skills (e.g., communication, teamwork and rapid decision-making) in a stressful environment. 2 3 The flow-on effects of intra-operative stress may have the potential to impair surgical performance, worsen patient outcome, and contribute to a chronic stress phenotype. 2-5 Therefore, the application of stress mitigation strategies within the operating room (OR) is important to ensure the ongoing delivery of excellent surgical care, and to promote workforce sustainability. 6 Music is regularly played in ORs throughout the world and is a common way in which surgeons can alter their operating environment. 7-11 Many surgical clinicians find music to be a generally favorable part of the theatre environment, 9-13 with music being seen as improving calmness, 7 stress, 14 15 mood, 10 surgeon and overall team performance, 9 however concerns remain over its distracting properties and risk to disrupt communication. 12 14 16 17 We have previously documented the challenges of investigating the effects of music on surgeon physiological and psychological parameters in the in-situ OR environment, due multiple confounding variables such as heterogeneity in case complexity, unexpected complications and experience of team members. An alternative approach to investigate the effect of environment on a surgeon’s experience of stress and task performance is a surgical simulation task, as this permits superior control of confounding variables and more extensive physiological monitoring. 19 For example, Oomens et al observed that music improved task performance, instrument handling efficiency and reduced SURG-TLX parameters during a simple surgical simulation task (i.e., laparoscopic peg transfer) in medical students. 20 However it remains unknown if beneficial effects would be observed for tasks with a higher level of complexity and in more experienced operators. The objective of the present study was to conduct a randomized controlled interventional trial using a complex simulated surgical task (i.e., carotid patch-angioplasty) to test the primary hypothesis that music reduces an operator’s psychological and physiological stress response to a simulated surgical task. We also included a direct comparison of the effect of music on inexperienced (i.e., undergraduate medical students) versus experienced (i.e., trained surgeons) operators to extend and permit comparisons with previous research identifying that preferred music improves performance and reduces mental workload in inexperienced operators during the learning phase of a new and challenging surgical task 20-22 . The inclusion of such groups enhances the ecological validity of these novel investigations, while potentially informing the design of future studies examining psychophysiological stress and its mitigation in simulated surgery. METHODS Ethics The Effect of background music on STress Responses Amongst Undergraduates and Surgeons performing Simulated Surgical tasks: A randomised cross-over interventional trial (The STRAUSS study) was a non-blinded controlled crossover trial with balanced allocation carried out at the Faculty of Health and Medical Sciences, University of Auckland between April and October 2023. The STRAUSS study was designed in accordance with the CONSORT guidelines with the crossover study extension to randomised crossover trials. 23 24 This interventional trial was registered with the World Health Organisation International Clinical Trials Registry Platform (Universal Trial Number: U1111 1288-7255, 20/02/2023), the Australia and New Zealand Clinical Trials Registry (ANZCTR reference: ACTRN12623000306617, 20/3/2023) and was approved by the New Zealand Health and Disability Ethics Committee (HDEC 20/CEN/57) and conformed to the standards in the Declaration of Helsinki (2013). All participants provided explicit written informed consent prior to commencement. Participants Eligible participants were undergraduate medical students (inexperienced/MS) and senior vascular trainee surgeons or vascular consultant surgeons (experienced/VS). Participants were excluded if they had a significant physical impairment that inhibited dextrous task completion, current pregnancy, a significant cardiac history, or a hearing impairment in which the auditory perception of music was not possible. Participants were asked to refrain from caffeine, cardioactive medications and strenuous exercise 12 hours prior to the study. Each participant had anthropometric and demographic information gathered. Trial Protocol and Randomisation Participants were in the seated position with a table in front of them. After at least 5 minutes at rest, baseline physiological (5 minutes) and psychological measures were recorded. Using a Vascular Micro-Surgery Head Simulator (More Than Simulators™, Barcelona, Spain), participants were asked to perform a patch-angioplasty anastomosis using a double armed 5-0 prolene suture and a bovine pericardial patch (Xenosure™, Le Maitre) to a 1.5 cm long arterial defect in a 6 mm bio-synthetic tubegraft (Omniflow ™, Le Maitre) that served as a carotid artery (Figure 1). MS participants each had a period of initial training in which they were shown a five-minute video of a patch-angioplasty anastomosis and then were trained to perform the task on the model by the researcher (A.N.). VS participants were allowed to perform the task once to familiarise themselves with the surgical model during the training phase. All participants were then instructed to perform the surgical task a total of four times, randomised (by coin toss) to music or a no-music control using a block of size two. This ensured that each participant performed the task twice under each condition, once each in the first half and second half of the protocol. Participants were instructed to perform the task as neatly and quickly as possible, and an researcher observed their work while taking notes on a clipboard. A camera was set up in the corner of the room, focused on the participants hands. After the training period and after each task was completed, there was a rest period of approximately five-minutes (Figure 1). Participants started from a resting position, and the task was considered complete when they had trimmed the final knot. Blinding was not possible with this study design, so allocation concealment was utilised. Participants were informed of the allocation at the time of commencement of the task and were kept blinded to the randomisation method. The intervention was participant selected music, with a choice of playlist, artist, or genre radio from Spotify™. The no-music control condition was a recorded sound clip of ambient theatre noise. 25 Both conditions were played through noise cancelling headphones at a medium volume acceptable to the participant. Experimental Measures The primary performance outcome measures were time to task completion, number of errors, self-rated performance on the Global Rating Scale 26 and two anastomotic quality scales: The 10-point Microsurgical Anastomosis Rating Scale (MARS10) 27 the End-Product Rating Scale (EPRS). 28 Primary psychological outcome measures were the Six-Item State Trait Anxiety Inventory (STAI-6) and a Surgical Taskload Index (SURG-TLX) completed at baseline and immediately on task completion after each of the four trials. The STAI-6 has reported strong internal reliability, to be highly correlated with the full STAI, and it has been used in many healthcare settings. 29-31 Each component of the STAI-6 could possibly score between 1 and 4, with a minimum total score of 6 and maximum score of 24. 32 The SURG-TLX is a multidimensional, surgery-specific workload measure that was developed and validated specifically for use in surgery from the NASA Task-load Index. 33 The highest possible score for the total SURG-TLX is 126, and the minimum score is 6, with each of 6 domains scored between 1 and 21. 33 A higher score represents higher task-load. Participants were instrumented for continuous monitoring of heart rate (HR) by a lead II electrocardiogram (BioAmp, FE231, ADInstruments, Bella Vista, NSW, Australia) and intermittent monitoring of blood pressure by an automated digital sphygmomanometer fixed to the left upper arm (HEM-7121, Omron Healthcare, Kyoto Japan) (Figure 1). Mean arterial pressure (MAP) was calculated post-hoc. Respiratory frequency (R f ) and partial pressure of end-tidal carbon dioxide (P ET CO 2 ) were monitored continuously via a single-nostril nasal cannula using a gas analyzer (Respiratory Gas Analyzer, ML206, ADInstruments) calibrated using standard gases. Middle cerebral artery mean blood velocity (MCA Vm) was measured by transcranial Doppler ultrasonography (ST3, Spencer Technologies, Redmond, WA, USA). Blood velocity in the M1 segment of the middle cerebral artery was measured using a 2 MHz probe fixed over the temporal window with an adjustable headband. The M1 segment was identified using search techniques described elsewhere (Aaslid et al., 1982; Willie et al., 2011). Data Analysis Raw signals underwent analog-to-digital conversion at 1 kHz (Powerlab and LabChart v8; ADInstruments) and were stored for offline analysis. From the ECG, HR was calculated on a beat-to-beat basis. Breath-by-breath R f and P ET CO 2 were obtained, and artefacts were removed. Raw physiological responses were averaged over a 1-minute period at four timepoints: rest ( 3 minutes prior to task commencement ), the start of the task ( immediately after commencement) , the isometric midpoint of the task, and the end of the task ( immediately prior to completion ). R-R intervals were extracted from ECG data over a 5-minute period at the overall resting baseline and the isometric midpoint of the task and subsequently analysed in line with the European Society of Cardiology (ESC) and the North America Society of Pacing and Electrophysiology standards of measurement of heart rate variability. 34 The ECG data were independently assessed and verified to exclude any artefacts, pauses, ectopics, and analysis was performed using HRV software (Kubios, Finland) with medium beat correction. 35 Time domain: RMSSD (square root of the mean of the sum of the squares of differences between adjacent NN intervals), frequency domain: LF:HF ratio (HF, high frequency [0.15 – 0.4 Hz]; LF, low frequency [0.04 – 0.15 Hz]) and composite scores of the parasympathetic nervous system (PNS), sympathetic nervous system (SNS) and Baevsky’s stress indices were reported. 35 36 Statistical Analysis Based on our previous work showing that mean operative SURG-TLX amongst surgeons was 48±22, it was estimated that a total of 20 participants would be sufficient to detect a 30% difference between music and control conditions. Normality was assessed visually and with QQ plots. Performance outcomes were summarised and compared between trial arms with a two-tailed paired t-test. Psychological and HRV outcomes were compared with a two-way repeated measures ANOVA with group (MS, VS) and condition (baseline, music, control) as the main effects. Physiological outcomes were compared using three-way repeated measures ANOVA with group (MS, VS), condition (music, control), and time (baseline, start, midpoint, end) as main effects. Tukey’s test was used for post-hoc analysis of significant main effects and interactions. Statistical significant was accepted at p<0.05. Pairwise deletion was used for missing data. Data are presented as mean ± standard deviation unless otherwise stated. Statistical analysis was carried out using R and R Studio (v2022.07.0) 37 and GraphPad Prism version 10.0.0 for Windows (GraphPad Software, Boston, Massachusetts USA). 38 RESULTS Protocol adherence The protocol was well tolerated. All MS participants were able to learn and perform the surgical tasks, and all participants completed the protocol. The music intervention and control conditions did not need to be turned off for any participant. Participant Characteristics The MS group (n=15) were aged 23±2.7 years (mean±SD), with a height and weight of 170±10 cm and 67±21 kg, respectively. Ten (67%) were female and five (33%) were students who were in the first three university-based years of the undergraduate degree, and the remaining were in their final three hospital-based years. The pop genre was the most popular choice of the music intervention (n=4), although choices also included classical, Rhythm and blues, atmospheric instrumental, jazz and metal. The VS group (n=12) were older (42±10 years; p<0.0001 vs. MS), taller (179±8 cm; p=0.01), heavier (81±12 kg; p=0.04) and more likely to be male (p<0.01). There was 1 female participant and 8 were consultant surgeons. The most popular choices in the VS group were pop, easy listening and 80s music equally Surgical Performance Figure 2 illustrates the mean performance measures for the surgical task. Significant group effects were observed for time to completion (F(1,25)=43.4, p<0.0001), errors (F(1,25)=28.9, p<0.0001), and global rating scale (F(1,25)=16.4, p=0.0004). The VS cohort (mean difference of main effect, 95% CI) were faster to complete the task (-10 minutes [-13.2 - -6.8]), made fewer errors (-4 [-7 - -3]) and had higher self-rated scores (6 [2-9]). Music did not affect time to completion, number of errors or global rating scale (i.e., no condition effect was observed). Psychological Responses SURG-TLX total score and STAI-6 total score for baseline, music, and control (condition main effect) for MS and VS (group main effect) are shown in Figure 3 and Table 2. There was an interaction between condition and group for SURG-TLX total score (F(2,50) = 12.36, p<0.0001). MS exhibited pronounced increases from baseline by D40 [26-55, p<0.0001] with music, and by D44 [31-57, p<0.0001] with control, that tended to be greater than VS who exhibited increases from baseline by D17 [7-28, p<0.01] in music and by D17 [8-27, p<0.01] in control. SURG-TLX total score was not different between music and control in either group (MS p=0.392 VS p=1.000). A significant main effect of condition was noted for STAI-6 total scores (F(1.9,48.3)=18.7, P<0.0001), with an increase from baseline to control (D3 [1.7-4.3], p<0.0001) and baseline to music (D3 [1.4-4.3], p=0.0001), but no difference observed between music and control (-0.15 [-1.4-1.1], p=0.955). Physiological Responses Figure 4 demonstrates the HR, MCA Vm, P ET CO 2 , and RR responses to the surgical task at four timepoints (rest, start, midpoint and end; time main effect), in MS and VS (group main effect), for music and no music (condition main effect). HR increased from baseline at all timepoints (time main effect; F(3,75)=14.2, p<0.0001) and reached a peak at the end of the task (D5.1bpm [3.0-7.1] vs. baseline, p<0.0001). HR was lower in VS (group main effect; F(1,25)=14.8, p=0.0007) but was not affected by music (condition main effect; p=0.204). Similarly, MCA Vm was increased from baseline at all timepoints during the task (time main effect; F(3,75)=36.8, p<0.0001) and was lower in VS (group main effect; F(1,25)=9.2, p=0.006), but was not affected by music (condition main effect; F(1,25)=3.0, p=0.094). P ET CO 2 increased during the task (time main effect; F(3,75)=15.8, p<0.0001) reaching a peak at the midpoint (+1.5 [0.95-2.1] mmHg, p<0.0001), and overall was lower with music (condition main effect; F(1,25)=5.0, p=0.034). RR increased only at the end of the task (time main effect; F(3,75)=2.9, p=0.040; +1.7 [0.3-3.0] bpm vs baseline, p<0.01). MAP was higher in VS than MS (group main effect; F(1,25)=6.0, p=0.022), although not different between conditions (condition main effect; F(1,25)=0.05, p=0.822). HRV Responses HRV parameters for the baseline, music, and control conditions, in the MS and VS groups, are shown in Table 1 and Figure 5. For PNS Index, there was a main effect of condition (F(1.1,27.8)=17.5, p=0.0002). with PNS Index being lower than baseline in both control (-0.45 [-0.73 - -0.18], p<0.0009) and music (-0.57 [-0.91 - -0.23], p<0.0009), and lower in music than control (-0.11 [-0.22 - -0.008], p=0.032). There was also a main effect of group (F(1,25)=5.9, p=0.023), such that MS had a lower PNS index (-0.8 [-1.5- -0.12]) than VS. There was a main effect of condition (F(1.1,28.3)=12.6, p=0.001) for SNS Index with values being higher than baseline during both control (0.54 [0.96 – 0.13], p<0.009) and music (0.68 [0.22 – 1.14], p<0.003), and higher during music than control (0.14 [0.004 – 0.27], p=0.042). SNS index was higher in MS than VS (group main effect F(1,25)=6.2, p=0.019; D+1.0 [0.17-1.8]). There was a main effect of condition for RMSSD (F(1.2, 30.2)=5.6, p=0.020), with a tendency for a decrease from baseline during music (-5.98 [-12.4-0.48], p=0.073) and control (-3.72 [-8.9-1.4], p=0.192), and lower values during music than control (-2.3 [-4.7-0.24], p=0.081). Total power also exhibited a main effect of condition (F(1.3,32.3)=3.9, p=0.046), with lower values in music than control (-322 [-624 - -20], p=0.035). There was a main effect of condition for high frequency parameters (F(1.3,32.2)=4.2, p=0.038), though no significant results on post-hoc analysis. There were no significant main effects or interactions noted for low frequency power and LF/HF ratio, while there was an interaction between condition and group for Baevsky’s stress index (F(2,50)=3.6, p=0.035), although no significant post hoc differences were observed. DISCUSSION This study examined the effect of background music on performance, and the psychological and physiological responses to a complex simulated surgical task under stressful circumstances. The five major novel findings were, 1) music did not affect either the speed or accuracy of the simulated surgical stress task performance, 2) the task increased subjective ratings of anxiety and task load but these were unaffected by music, 3) HR, MCA Vm, P ET CO 2 , RR, and SNS index were increased, while PNS index decreased during the task, indicative of a physiological stress response, 4) PNS index was reduced and SNS index was increased in the presence of music suggestive of an arousal response, and finally 5) the more experienced group (VS) performed faster, with fewer errors and greater self-rating than the inexperienced (MS) group, and had overall lower HR, MCA Vm and MAP, but there were no psychological or physiological differences between VS and MS in their responses to music. Task Performance A beneficial effect of music on simulated surgical task performance was not demonstrated in the present study in either inexperienced (MS) or experienced (VS) operators. This is out of keeping with El Boghdady’s systematic review that concluded classical music at a low to medium volume improves accuracy and speed, and outweighs negative effects of distractedness, on the basis of n=18 studies that were predominantly simulation studies and surveys. 39 This may in part be due to the novel use of a complex, non-laparoscopic surgical model of carotid patch-plasty in this field of research, a task that required the performance of multiple surgical steps (i.e. knot tying, suturing, patch trimming) which may take variable lengths of time. To investigate this variable, future research may consider utilising a study design that includes a complex multi-step task in comparison to a simple task. Music has also been shown to hasten the learning process of surgical tasks on the Da Vinci robot. 21 In the present study, there was no music or sound during the training phase of the protocol, and future research could investigate the effect of music on the learning trajectory of complex surgical tasks and speed of skill acquisition. Psychological Stress During task performance, SURG-TLX scores increased to a mean of 64 for MS and 47 for VS. SURG-TLX scores of this magnitude during tasks are similar to that observed in surgeons performing cardiac surgery (SURG-TLX= 48 points) or breast and vascular surgery (48 points), with scores over 50-55 points associated with increased risk of error. 18 40-42 Despite the simulated carotid patch-angioplasty task inducing a clear stress response from operators, this was not modified by music in either the VS or MS group. Background music decreased workload scores in two previous studies of inexperienced operators performing simulated laparoscopic surgery 19 20 The possible reasons for the conflicting findings of the present study include the nature of the control condition (silence vs. ambient OR noise) and the nature of simulated task. SURG-TLX measured reproducible changes from baseline in the participants in this study. Other authors have preliminary recommended the SURG-TLX as a standard measure to assess operators’ experience in studies of surgical innovation, as it has been found to be most relevant, comprehensive, and comprehensible. 43 STAI-6 scores increased during task performance (around 3 points in both groups), though the level of experience did not affect this increase. STAI-6 has been frequently used validated scale for stress measurement and has successfully been demonstrated to correlate to LF/HF though a direct comparison between STAI-6 and SURG-TLX has yet to be published. 44 Physiological Stress The data here represents the most detailed physiological phenotype of a surgeon performing a simulated task to date. 45 46 In other studies, during surgery, mean HR has been measured to be the most consistent biomarker elevated by 6 to 22 bpm from baseline compared to 5 bpm in this study. 46 In our study, there was no difference in HR between music and control conditions. Analysis of HRV has been shown to be a good objective assessment of mental stress in the surgical setting. 47 Notably, we observed that music reduced the PNS index and increased the SNS index, suggestive of sympathetic predominance, which is contrary to widespread perception of OR music, and previous interventional studies. 9 10 20 45 Further evidence for an arousal response to music is the lowering of P ET CO 2 , which would fit with an increase in minute ventilation under the music condition. Allen et al suggested that self-selected music could reduce skin conductance, pulse and blood pressure and improve speed and accuracy of arithmetic tasks when compared to control music or the absence of music. 48 One study reported an increase in MAP between control and self-selected music, 49 though four other studies also demonstrated no change in HR or MAP under music conditions compared to control. 45 Finally, relaxing music (slow-paced classical pieces) when compared to control showed greater return to baseline in high frequency HRV after a stressing event suggesting a role for music in the recovery for surgeons after stressful operations. 50 Transcranial Doppler ultrasound was first used by Aaslid et al 51 to measure cerebral blood velocity in dynamic cerebral autoregulation research, and its application to surgeons is novel. Cerebral perfusion (i.e., MCA Vm) was significantly increased during task performance, with maximal increase during the midpoint of the operation, although a difference between music and control conditions was not observed. The cerebrovascular changes during task performance reported in this study are not surprising, in that MCA Vm has been shown to increase bilaterally in mathematical cognitive effort, 52 and during simulated robot assisted surgery, the pre-frontal cortex (supplied by the MCA and anterior cerebral artery) differentially activates. 53-55 The functional hyperaemia we observed may be linked to neuronal activation during the surgical task (i.e., neurovascular coupling), but the coincident elevation in P ET CO 2 (a proxy for arterial CO 2 concentration a powerful cerebrovascular vasodilator) during task performance is also likely to be a contributory factor. 56 The nature of the task meant that non-invasive beat-to-beat blood pressure could not be measured using finger photoplethysmography, hence cerebral perfusion pressure estimates cannot be incorporated into the interpretation of the MCA Vm response. 57 It should be noted that transcranial Doppler assesses artery blood velocity, rather than blood flow, and whether the this is representative of cerebral blood flow rests on the assumption that vessel diameter remains constant. The impact of experience The VS cohort were older, taller, heavier, and contained more males which may account for the baseline group main effects between groups (i.e. lower HR, lower MCA Vm, higher MAP). Unsurprisingly, the greater experience was associated with improved speed and quality of the task performance. 58 59 A time x group interaction in HR is suggestive of attenuated cardiovascular reactivity to the task in the VS group, for whom the surgical task would have been more familiar. This is in line with previous work that has shown senior surgeons to display a better stress management capacity and are less prone to cognitive distraction compared to junior surgeons. 60 61 Future work should then consider that if music were to attenuate a psychophysiological response to surgical tasks, this effect may be less detectable in an experienced population where the stress response to tasks is smaller. The type of music The question often arises as to whether the type of music is important. Self-selected music is a commonly researched music choice in the surgical setting, in part due to Allen et al ’s seminal paper, and was therefore used in this study. 45 48 62 Music considered to be unpleasant may generate poorer surgical performance, an effect which may be measurable through application of electro-encephalography. 63 64 Dissonance in music has been shown to induce unpleasant feelings and physiological responses which may lend support to the application of consonant music. 65 Furthermore, faster music may reduce OR preparation time, 66 increase the rate of task performance (while also increasing the number of mistakes), 67 greater sound intensity can increase perceived arousal and high rhythmic tension may more strongly affect heart rate variability. 68 Strengths and Limitations Several experimental considerations should be considered when interpreting the results of the present investigation. The crossover design was counterbalanced to minimise possible learning effects and all participants undertook a supervised training and practice period prior to being assessed to further mitigate against learning effects. To increase the experience of stress during the surgical task several experimental manipulations were employed. The Trier Social Stress Test is an ecologically valid stressor induced by public speaking, and in the present study and social evaluation was incorporated with the presence of an unresponsive yet engaged assessor and a camera setup (without filming). 69 Perceived time pressure refers to the sense of time pressure experienced in the absence of genuine time limits and has been shown to be an empirical stressor, and was also incorporated into the study design. 70 Finally, participants were asked to complete task to the highest quality possible to maintain a level of sustained mental effort investment during the protocol in an aim to increase mental workload, stress and fatigue during the task. 71 The results indicate that the task and the applied manipulation were successful in generating a stress response. It is rarely silent in a working operating room, thus ambient theatre noise was selected as the control condition. 72 As such it is possible that previous work showing that music improved simulated laparoscopy compared to a no music / silence control may be due to the presence of auditory stimulation (or the absence of silence), rather than the music itself. 20 Conclusion We observed that the performance of a simulated carotid patch-angioplasty under stressing conditions successfully increased markers of psychological and physiological stress in both inexperienced and experienced operators. Despite previous research identifying generally positive surgeon perceptions, background music did not improve either surgical task performance or attenuate subjective ratings of task load and anxiety, but in fact evoked additional physiological arousal evidenced by decreased PNS index and increased SNS index. As expected, the more experienced group performed faster and more accurately than the inexperienced group, but there were no psychological or physiological differences in their responses to music. Declarations Acknowledgments The authors would like to thank Dr Michael Plunkett, Thalia Babbage, Dr Ana Sayegh, Dr Mickey Fan and Harvey Walsh from the University of Auckland Human Cardiovascular Physiology Lab for their assistance with data collection, Dr Alana Cavadino for biostatistical support, Lois Blackwell and Nicky Cockrem for administrative support, the University of Auckland Clinical Research Centre and all the surgeons and students that participated in the protocol. Ethics This interventional trial was registered with the World Health Organisation International Clinical Trials Registry Platform (Universal Trial Number: U1111 1288-7255) and the Australia New Zealand Clinical Trials Registry (ANZCTR reference: ACTRN12623000306617). Ethics approval was granted by the New Zealand Health and Disability Ethics Committee (HDEC 20/CEN/57 2023 AM 9287). Funding Funding for this work was received from The Specialty Trainees of New Zealand (STONZ) Research Grant, The Australian and New Zealand Society for Vascular Surgery and The Royal Australasian College of Surgeons Aotearoa New Zealand Research Scholarship. The materials used in the surgical model (Omniflow™ and Xenosure™) were kindly donated by LeMaitre Vascular Ltd. LeMaitre had no input or oversight at any stage during the trial and did not contribute to the project in any other way. Data Availability Statement The datasets generated and analysed during the current study are not publicly available due participant confidentiality but de-identified and anonymous data are available from the corresponding author upon reasonable request. Conflicts of Interest The authors have no conflicts of interest to declare. Author Contribution AN: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review & Editing, Visualization, Supervision, Project administration, Funding acquisitionMK: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review & Editing, Visualization, Supervision, Project administration, Funding acquisition, JPF: Conceptualization, Methodology, Software, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review & Editing, Supervision, Project administration, Funding acquisition. All authors reviewed the manuscript. References Arora S, Flindall I, Youngson GG. Performance-shaping factors. In: Flin R, Youngson GG, Yule S, eds. Enhancing surgical performance: A primer in non-technical skills: CRC press 2015. Arora S, Hull L, Sevdalis N, et al. Factors compromising safety in surgery: stressful events in the operating room. American journal of surgery 2010;199(1):60–5. doi: 10.1016/j.amjsurg.2009.07.036 [published Online First: 2010/01/28] Arora S, Sevdalis N, Nestel D, et al. The impact of stress on surgical performance: a systematic review of the literature. Surgery 2010;147(3):318 – 30, 30 e1-6. doi: 10.1016/j.surg.2009.10.007 [published Online First: 2009/12/17] Sharma A, Sharp DM, Walker LG, et al. Stress and burnout in colorectal and vascular surgical consultants working in the UK National Health Service. Psychooncology 2008;17(6):570–6. doi: 10.1002/pon.1269 [published Online First: 2007/10/16] Shanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg 2009;250(3):463–71. doi: 10.1097/SLA.0b013e3181ac4dfd [published Online First: 2009/09/05] Erestam S, Bock D, Andersson AE, et al. The perceived benefit of intraoperative stress modifiers for surgeons: an experimental simulation study in volunteers. Patient safety in surgery 2021;15(1):23. doi: 10.1186/s13037-021-00294-6 [published Online First: 2021/05/31] Ullmann Y, Fodor L, Schwarzberg I, et al. The sounds of music in the operating room. Injury 2008;39(5):592–7. doi: 10.1016/j.injury.2006.06.021 [published Online First: 2006/09/23] Hawksworth C, Asbury AJ, Millar K. Music in theatre: not so harmonious. A survey of attitudes to music played in the operating theatre. Anaesthesia 1997;52(1):79–83. [published Online First: 1997/01/01] Narayanan A, Gray AR. First, do no harmony: an examination of attitudes to music played in operating theatres. New Zealand Medical Journal 2018;131(1480):68–74. Narayanan A, Naidoo M, Kong VY, et al. Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective. South African journal of surgery Suid-Afrikaanse tydskrif vir chirurgie 2023;61(1):30–38. [published Online First: 2023/04/14] Narayanan A, Naidoo M, Kong V, et al. Broad Responses and Attitudes to Having Music in Surgery (The BRAHMS Study): An Australia and Aotearoa New Zealand Perspective. Surgery Open Science 2024;17:30–34. doi: https://doi.org/10.1016/j.sopen.2023.12.009 Faraj AA, Wright P, Haneef JH, et al. LISTEN WHILE YOU WORK? The Attitude of Healthcare Professionals to Music in the OR. Ornac J 2015;33(2):31–2, 34–50. Fu VX, Oomens P, Merkus N, et al. The Perception and Attitude Toward Noise and Music in the Operation Room: A Systematic Review. Journal of Surgical Research 2021;263:193–206. Makama JG, Ameh EA, Eguma SA. Music in the operating theatre: opinions of staff and patients of a Nigerian teaching hospital. Afr Health Sci 2010;10(4):386–89. George S, Ahmed S, Mammen KJ, et al. Influence of music on operation theatre staff. Journal of Anaesthesiology Clinical Pharmacology 2011;27(3):354–57. Way TJ, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. Journal of the American College of Surgeons 2013;216(5):933–8. doi: 10.1016/j.jamcollsurg.2012.12.048 [published Online First: 2013/03/23] Cheriyan S, Mowery H, Ruckle D, et al. The Impact of Operating Room Noise Upon Communication During Percutaneous Nephrostolithotomy. J Endourol 2016;30(10):1062–66. doi: 10.1089/end.2016.0498 [published Online First: 2016/08/25] Narayanan A, Fisher JP, Khashram M. The MOSART Study - The effect of Music on the Operating Surgeon – A Randomised Trial. In: ANZSVS, ed. Australia and New Zealand Society of Vascular Surgery - Annual Scientific Conference. Gold Coast, Australia, 2021. Fu VX, Oomens P, Kleinrensink VEE, et al. The effect of preferred music on mental workload and laparoscopic surgical performance in a simulated setting (OPTIMISE): a randomized controlled crossover study. Surgical Endoscopy 2020 Oomens P, Fu VX, Kleinrensink VE, et al. The Effects of Preferred Music on Laparoscopic Surgical Performance: A Randomized Crossover Study. World journal of surgery 2020:1–6. Siu KC, Suh IH, Mukherjee M, et al. The effect of music on robot-assisted laparoscopic surgical performance. Surgical innovation 2010;17(4):306–11. doi: 10.1177/1553350610381087 [published Online First: 2010/09/08] Gil K, Jones M, Mouw T, et al. Satisfaction or Distraction: Exposure to Nonpreferred Music May Alter the Learning Curve for Surgical Trainees. Journal of surgical education 2020;77(6):1370–76. Schulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. doi: 10.1136/bmj.c332 [published Online First: 2010/03/25] Dwan K, Li T, Altman DG, et al. CONSORT 2010 statement: extension to randomised crossover trials. BMJ 2019;366:l4378. doi: 10.1136/bmj.l4378 Ambience Laboratory. Surgery Background Sounds 2. ASMR Ambience Hospital Youtube2022 [Available from: https://www.youtube.com/watch?v=s4HyneDVXi0 . Doyle JD, Webber EM, Sidhu RS. A universal global rating scale for the evaluation of technical skills in the operating room. American journal of surgery 2007;193(5):551–5; discussion 55. doi: 10.1016/j.amjsurg.2007.02.003 [published Online First: 2007/04/17] Stogowski P, Fliciński F, Białek J, et al. Microsurgical Anastomosis Rating Scale (MARS10): A Final Product Scoring System for Initial Microsurgical Training. Plast Surg (Oakv) 2021;29(4):243–49. doi: 10.1177/2292550320969649 [published Online First: 2021/11/12] Price J, Naik V, Boodhwani M, et al. A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: The role of deliberate practice. The Journal of Thoracic and Cardiovascular Surgery 2011;142(3):496–503. doi: https://doi.org/10.1016/j.jtcvs.2011.05.015 Marteau TM, Bekker H. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). The British journal of clinical psychology 1992;31(3):301–6. doi: 10.1111/j.2044-8260.1992.tb00997.x [published Online First: 1992/09/01] Court H, Greenland K, Margrain T. Measuring Patient Anxiety in Primary Care: Rasch Analysis of the 6-item Spielberger State Anxiety Scale. Value in health: the journal of the International Society for Pharmacoeconomics and Outcomes Research 2010;13:813–9. doi: 10.1111/j.1524-4733.2010.00758.x Bayrampour H, McDonald S, Fung T, et al. Reliability and validity of three shortened versions of the State Anxiety Inventory scale during the perinatal period. Journal of psychosomatic obstetrics and gynaecology 2014;35(3):101–7. doi: 10.3109/0167482x.2014.950218 [published Online First: 2014/08/16] Chlan L, Savik K, Weinert C. Development of a shortened state anxiety scale from the Spielberger State-Trait Anxiety Inventory (STAI) for patients receiving mechanical ventilatory support. Journal of nursing measurement 2003;11(3):283–93. doi: 10.1891/jnum.11.3.283.61269 [published Online First: 2005/01/07] Wilson MR, Poolton JM, Malhotra N, et al. Development and validation of a surgical workload measure: the surgery task load index (SURG-TLX). World journal of surgery 2011;35(9):1961–9. doi: 10.1007/s00268-011-1141-4 [published Online First: 2011/05/21] European Society of Cardiology. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation 1996;93(5):1043–65. [published Online First: 1996/03/01] Tarvainen MP, Niskanen JP, Lipponen JA, et al. Kubios HRV–heart rate variability analysis software. Computer methods and programs in biomedicine 2014;113(1):210–20. doi: 10.1016/j.cmpb.2013.07.024 [published Online First: 2013/09/24] Methodical Recommendations—Use Kardivar System for Determination of the Stress Level and Estimation of the Body Adaptability-Standards of Measurements and Physiological Interpretation.; 2009. R: A Language and Environment for Statistical Computing [program]. Vienna, Austria: R Foundation for Statistical Computing, 2023. Prism G. GraphPad Prism. GraphPad Software Inc 2020 El Boghdady M, Ewalds-Kvist BM. The influence of music on the surgical task performance: A systematic review. International journal of surgery (London, England) 2020;73:101 – 12. doi: 10.1016/j.ijsu.2019.11.012 [published Online First: 2019/11/25] Kennedy-Metz LR, Wolfe HL, Dias RD, et al. Surgery Task Load Index in Cardiac Surgery: Measuring Cognitive Load Among Teams. Surgical innovation 2020;27(6):602–07. doi: 10.1177/1553350620934931 Yu D, Lowndes B, Thiels C, et al. Quantifying Intraoperative Workloads Across the Surgical Team Roles: Room for Better Balance? World journal of surgery 2016;40(7):1565–74. doi: 10.1007/s00268-016-3449-6 [published Online First: 2016/03/10] Mazur LM, Mosaly PR, Jackson M, et al. Quantitative assessment of workload and stressors in clinical radiation oncology. International journal of radiation oncology, biology, physics 2012;83(5):e571-6. doi: 10.1016/j.ijrobp.2012.01.063 [published Online First: 2012/04/17] McNair AGK, Hoffmann C, Macefield RC, et al. A standardized measurement instrument was recommended for evaluating operator experience in complex healthcare interventions. Journal of Clinical Epidemiology 2023;153:55–65. doi: https://doi.org/10.1016/j.jclinepi.2022.10.006 Tjønnås MS, Guzmán-García C, Sánchez-González P, et al. Stress in surgical educational environments: a systematic review. BMC Med Educ 2022;22(1):791. doi: 10.1186/s12909-022-03841-6 [published Online First: 2022/11/17] Narayanan A, Pearson L, Fisher JP, et al. The effect of background music on stress in the operating surgeon: scoping review. BJS Open 2022;6(5) doi: 10.1093/bjsopen/zrac112 Budden A, Song S, Henry A, et al. A systematic review of biological changes in surgeons’ acute stress levels during surgery. Surgery in Practice and Science 2023;13:100174. doi: https://doi.org/10.1016/j.sipas.2023.100174 The AF, Reijmerink I, van der Laan M, et al. Heart rate variability as a measure of mental stress in surgery: a systematic review. Int Arch Occup Environ Health 2020;93(7):805–21. doi: 10.1007/s00420-020-01525-6 [published Online First: 2020/03/28] Allen K, Blascovich J. Effects of music on cardiovascular reactivity among surgeons. Jama 1994;272(11):882–4. Mitta N, Jayakumar V, Dhanpal N, et al. Surgical Notes: To Play or Not to Play. World journal of surgery 2019;43(11):2740–46. Baccarani A, Donnadieu S, Pellissier S, et al. Relaxing effects of music and odors on physiological recovery after cognitive stress and unexpected absence of multisensory benefit. Psychophysiology 2023;60(7):e14251. doi: https://doi.org/10.1111/psyp.14251 Aaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. Journal of neurosurgery 1982;57(6):769–74. doi: 10.3171/jns.1982.57.6.0769 [published Online First: 1982/12/01] Montoro CI, Duschek S, Reyes del Paso GA. Variability in cerebral blood flow velocity at rest and during mental stress in healthy individuals: Associations with cardiovascular parameters and cognitive performance. Biological Psychology 2018;135:149–58. doi: https://doi.org/10.1016/j.biopsycho.2018.04.005 Izzetoglu K, Aksoy ME, Agrali A, et al. Studying Brain Activation during Skill Acquisition via Robot-Assisted Surgery Training. Brain sciences 2021;11(7) doi: 10.3390/brainsci11070937 [published Online First: 2021/08/07] Patel R, Suwa Y, Kinross J, et al. Neuroenhancement of surgeons during robotic suturing. Surgical endoscopy 2022;36(7):4803–14. doi: 10.1007/s00464-021-08823-1 [published Online First: 2021/11/02] Hannah TC, Turner D, Kellner R, et al. Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review. Frontiers in human neuroscience 2022;16:705238. doi: 10.3389/fnhum.2022.705238 [published Online First: 2022/03/08] Purkayastha S, Sorond F. Transcranial Doppler ultrasound: technique and application. Seminars in neurology 2012;32(4):411–20. doi: 10.1055/s-0032-1331812 [published Online First: 2013/01/31] Fan J-L, Nogueira RC, Brassard P, et al. Integrative physiological assessment of cerebral hemodynamics and metabolism in acute ischemic stroke. Journal of Cerebral Blood Flow & Metabolism 2022;42(3):454–70. doi: 10.1177/0271678x211033732 Rothbaum DL, Roy J, Hager GD, et al. Task Performance in Stapedotomy: Comparison Between Surgeons of Different Experience Levels. Otolaryngology–Head and Neck Surgery 2003;128(1):71–77. doi: 10.1067/mhn.2003.13 Loukas C, Gazis A, Kanakis MA. Surgical Performance Analysis and Classification Based on Video Annotation of Laparoscopic Tasks. JSLS: Journal of the Society of Laparoendoscopic Surgeons 2020;24(4) doi: 10.4293/jsls.2020.00057 [published Online First: 2020/11/05] Marrelli M, Gentile S, Palmieri F, et al. Correlation between Surgeon's experience, surgery complexity and the alteration of stress related physiological parameters. PLoS One 2014;9(11):e112444. doi: 10.1371/journal.pone.0112444 [published Online First: 2014/11/08] Hsu KE, Man FY, Gizicki RA, et al. Experienced surgeons can do more than one thing at a time: effect of distraction on performance of a simple laparoscopic and cognitive task by experienced and novice surgeons. Surgical endoscopy 2008;22(1):196–201. doi: 10.1007/s00464-007-9452-0 Oomens P, Fu VX, Kleinrensink VEE, et al. The Effects of Preferred Music on Laparoscopic Surgical Performance: A Randomized Crossover Study. World journal of surgery 2020;44(8):2614–19. Miskovic D, Rosenthal R, Zingg U, et al. Randomized controlled trial investigating the effect of music on the virtual reality laparoscopic learning performance of novice surgeons. Surgical endoscopy 2008;22(11):2416–20. doi: 10.1007/s00464-008-0040-8 [published Online First: 2008/07/16] Sammler D, Grigutsch M, Fritz T, et al. Music and emotion: Electrophysiological correlates of the processing of pleasant and unpleasant music. Psychophysiology 2007;44(2):293–304. doi: https://doi.org/10.1111/j.1469-8986.2007.00497.x Dellacherie D, Roy M, Hugueville L, et al. The effect of musical experience on emotional self-reports and psychophysiological responses to dissonance. Psychophysiology 2011;48(3):337–49. doi: https://doi.org/10.1111/j.1469-8986.2010.01075.x Mosaed S, Vahidi R, Lin KY. Effect of music tempo on operating room preparation time. Journal of perioperative practice 2020;30(5):141–44. Dalton B, Behm D. Effects of noise and music on human and task performance: A systematic review. Occupational Ergonomics 2007;7:143–52. Mikutta CA, Schwab S, Niederhauser S, et al. Music, perceived arousal, and intensity: Psychophysiological reactions to Chopin's “Tristesse”. Psychophysiology 2013;50(9):909–19. doi: https://doi.org/10.1111/psyp.12071 Allen AP, Kennedy PJ, Dockray S, et al. The Trier Social Stress Test: Principles and practice. Neurobiology of stress 2017;6:113–26. doi: 10.1016/j.ynstr.2016.11.001 [published Online First: 2017/02/24] Sussman RF, Sekuler R. Feeling rushed? Perceived time pressure impacts executive function and stress. Acta psychologica 2022;229:103702. doi: 10.1016/j.actpsy.2022.103702 [published Online First: 2022/08/20] Fairclough S, Mulder B. Psychophysiological processes of mental effort investment2012:61–76. Katz JD. Noise in the operating room. Anesthesiology 2014;121(4):894–8. doi: 10.1097/aln.0000000000000319 [published Online First: 2014/06/01] Tables Table 1 . Heart rate variability parameters at baseline and during the simulated surgical task under music and control (non-music) conditions in the medical student (MS) and vascular surgeon (VS) groups. Baseline Music Control ANOVA P values MS VS MS VS MS VS Condition Group Interaction RMSSD (ms) 38.4±16.3 43.4±27.3 36.3±12.7 32.6±15.5 37.5±12.9 36.2±20.4 0.020 0.997 0.080 Total power (ms 2 ) * 2144±1427 2521±2008 2012±1107 1356±853 2249±1340 1783±1313 0.045 0.596 0.069 High frequency (ms 2 ) 788±708 752±1027 549±394 434±397 541±319 609±679 0.038 0.898 0.649 Low frequency (ms 2 ) 1253±835 1598±1349 1262±677 845±508 1497±809 1062±589 0.139 0.501 0.055 LF/HF ratio 2.1±1.5 3.6±3.8 2.9±1.7 2.8±1.8 2.9±1.7 3.1±2.5 0.834 0.400 0.296 Baevsky’s Index 11.1±5.0 9.2±2.8 10.8±2.1 12.1±4.4 10.7±1.9 11.4±4.3 0.150 0.971 0.035 Values are mean with standard deviations for MS (n=15) and VS (n=12). P values show the results of two-way repeated measures analysis of variance. Results of post-hoc analysis with Tukey HSD shown as * = p<0.05 Music vs Control, RMSSD, root mean square of successive differences; LF/HF ratio, Low frequency/high frequency ratio. Table 2 . Psychological parameters at baseline and during the simulated surgical task under music and control (non-music) conditions in the medical student (MS) and vascular surgeon (VS) groups. Baseline Music Control ANOVA P values MS VS MS VS MS VS Condition Group Interaction STAI-6 Total score ### † †† † 9±3 10±2 12±3 12±3 13±3 12±3 <0.0001 0.854 0.376 Calm #### †††† 2±1 2±1 3±1 2±1 3±1 2±1 0.0003 0.837 0.268 Relaxed ## †††† 2±1 2±1 2±1 2±1 3±1 3±1 0.0001 0.864 0.135 Content ### †† 2±1 2±1 2±1 3±1 2±1 3±1 0.0003 0.489 0.789 Tense ## ††† 1±1 2±1 2±1 2±1 2±1 2±1 0.0002 0.529 0.967 Upset ## †† 1±0 1±0 1±1 1±1 1±1 1±0 0.002 0.922 0.807 Worried 1±1 1±0 1±1 1±0 1±1 1±0 0.691 0.453 0.174 SURG-TLX Total score #### †††† 22±18 30± 62±20 47±23 66±20 47±20 <0.0001 0.155 <0.0001 Mental Demands ## †† 4±3 8±5 12±5 9±5 12±5 9±4 0.002 0.002 0.017 Physical Demands ### †††† 3±4 4±2 9±6 8±5 10±6 7±4 <0.0001 0.014 0.044 Temporal Demands #### †††† 3±3 5±4 11±4 10±4 11±4 9±3 <0.0001 0.966 0.414 Task Complexity #### †††† 4±5 4±4 12±5 7±3 11±4 7±3 <0.0001 0.016 0.0002 Situational Stress ### †† 4±4 5±3 11±5 8±4 12±5 8±4 0.0004 0.031 0.101 Distractedness ## †††† 3±3 4±5 7±5 5±4 10±6 8±4 <0.0001 0.006 0.010 Values are mean with standard deviations for MS (n=15) and VS (n=12). P values show the results of two-way repeated measures analysis of variance. Results of post-hoc analysis with Tukey HSD shown as * = p<0.05 Music vs Control. # = p<0.05, ## = p<0.01, ### p<0.001, #### = p<0.0001 Baseline vs. Music. † = p<0.05, †† = p<0.01, ††† p<0.001, †††† = p<0.0001 Baseline vs Control. SURG-TLX, Surgical Taskload Index; STAI-6, Six-Item State-Trait Anxiety Inventory Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4225405","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":299847507,"identity":"d318a03e-dfa1-4e62-8ac3-f075479364c7","order_by":0,"name":"Anantha Narayanan","email":"data:image/png;base64,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","orcid":"","institution":"University of Auckland","correspondingAuthor":true,"prefix":"","firstName":"Anantha","middleName":"","lastName":"Narayanan","suffix":""},{"id":299847510,"identity":"d0dc77bd-5aca-4df8-ad52-f93af12e5308","order_by":1,"name":"Manar Khashram","email":"","orcid":"","institution":"University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"Manar","middleName":"","lastName":"Khashram","suffix":""},{"id":299847513,"identity":"8757cf1e-8b73-401f-824a-5a41a86f3964","order_by":2,"name":"James P Fisher","email":"","orcid":"","institution":"University of Auckland","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"P","lastName":"Fisher","suffix":""}],"badges":[],"createdAt":"2024-04-06 02:59:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4225405/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4225405/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1038/s41598-025-02202-9","type":"published","date":"2025-06-03T15:57:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":56196516,"identity":"3c30c900-9e63-4893-a926-b8ef8b216ddb","added_by":"auto","created_at":"2024-05-09 18:11:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1011889,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eExperimental set-up and timeline.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePanel A, the monitoring of blood pressure (BP; automated sphygmomanometer), middle cerebral artery flow velocity (MCA Vm; transcranial Doppler ultrasound – not seen), heart rate (HR; electrocardiography), respiratory frequency and partial pressure of end-tidal carbon dioxide (R\u003cem\u003ef\u003c/em\u003e and P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e; nasal cannula – not seen). Panel B, the surgical model with (from left top) suture scissors, suture holder, fine Potts scissors, Castro needle holder, Gerald forceps, head, and neck model with self-retained within wound, green drapes to cover the handles, and (from bottom left) 5-0 prolene suture packets, artery clip forceps, basic forceps. Panel C, the completed carotid patch-angioplasty procedure using a 5-0 prolene suture to join a bovine pericardial patch to the model artery (Omniflow™). Panel D, the experimental timeline (music or control intervention applied randomly with block size 2), psychological questionnaires were completed at Baseline 1, and upon immediate completion of tasks 1 to 4.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4225405/v1/8e170480decfbacba583288a.png"},{"id":56196578,"identity":"3b2589d5-5923-46f3-9062-65b166ca9ca4","added_by":"auto","created_at":"2024-05-09 18:11:28","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":43875,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSimulated surgical task performance measures in the music and control (non-music) conditions for the medical student (MS) and vascular surgeon (VS) groups.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSymbols represent individual values for MS (blue, n=15) and VS (red, n=12) with horizontal bars representing means with standard deviations. P values show results of two-way repeated measures analysis of variance.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4225405/v1/cea700b7453a711f230268ec.png"},{"id":56196374,"identity":"b4cc610a-2a5f-4fb3-8460-73ddcafe19d7","added_by":"auto","created_at":"2024-05-09 18:10:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":44501,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePsychological measures at baseline and during the simulated surgical task under music and control (non-music) conditions in the medical student (MS) and vascular surgeon (VS) groups.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSURG-TLX Total, Surgical Taskload Index; STAI-6, Total Six-Item State-Trait Anxiety Inventory Score. Symbols represent individual values for MS (blue, n=15) and VS (red, n=12) with horizontal bars representing means with standard deviations. P values show results of two-way repeated measures analysis of variance. Results of post-hoc analysis with Tukey HSD shown as ** = p\u0026lt;0.01 and **** = p\u0026lt;0.0001 versus Baseline.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4225405/v1/f9da6cc499673d7f4301d755.png"},{"id":56196514,"identity":"6ee34695-53eb-4702-be81-9daad70ab698","added_by":"auto","created_at":"2024-05-09 18:11:02","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":60461,"visible":true,"origin":"","legend":"\u003cp\u003ePanels show A, heart rate (HR); B, middle cerebral artery flow velocity (MCA Vm); C, partial pressure of end-tidal carbon dioxide (P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e, mmHg); D, respiratory rate (RR); and E, mean arterial pressure (MAP, mmHg). Values are expressed as mean with standard deviations for MS (green, n=15) and VS (n=12, purple). P values show the results of three-way repeated measures analysis of variance. Results of post-hoc analysis with Tukey HSD shown as * = p\u0026lt;0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePhysiological responses to the simulated surgical task under music and control (non-music) conditions in the medical student (MS) and vascular surgeon (VS) groups.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-4225405/v1/1ec57ae2e2cb384ee63ea7e1.png"},{"id":56196471,"identity":"2a130239-366f-45ff-94ad-3c71f899ac76","added_by":"auto","created_at":"2024-05-09 18:10:46","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":35345,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHeart rate variability parameters at baseline and during the simulated surgical task under music and control (non-music) conditions in the medical student (MS) and vascular surgeon (VS) groups.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePanels show A, parasympathetic nervous system index (PNS Index) and B, sympathetic nervous system index (SNS Index). Symbols represent individual values and horizontal bars show mean with standard deviations for MS (blue, n=15) and VS (red, n=12). P values show the results of two-way repeated measures analysis of variance. Results of post-hoc analysis with Tukey HSD shown as * = p\u0026lt;0.05 Baseline, # = p\u0026lt;0.05 vs. Control.\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-4225405/v1/ad0dabe350b26c724dab2e1e.png"},{"id":84242601,"identity":"c665e605-5311-4faf-ab8b-50abbf2b61af","added_by":"auto","created_at":"2025-06-09 16:10:08","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2505554,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4225405/v1/6fa8206e-49bb-4551-8419-38a0004b1d23.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of background music on STress Responses Amongst Undergraduates and Surgeons performing Simulated Surgical tasks: A randomised cross-over interventional trial (The STRAUSS Study)","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eIt is common for surgeons to experience stress while they are performing surgery.\u003csup\u003e1\u003c/sup\u003e High levels of physiological and/or psychological stress have the potential to interfere with the expert execution of technical and non-technical skills (e.g., communication, teamwork and rapid decision-making) in a \u0026nbsp;stressful environment.\u003csup\u003e2 3\u003c/sup\u003e The flow-on effects of intra-operative stress may have the potential to impair surgical performance, worsen patient outcome, and contribute to a chronic stress phenotype.\u003csup\u003e2-5\u003c/sup\u003e Therefore, the application of stress mitigation strategies within the operating room (OR) is important to ensure the ongoing delivery of excellent surgical care, and to promote workforce sustainability.\u003csup\u003e6\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMusic is regularly played in ORs throughout the world and is a common way in which surgeons can alter their operating environment.\u003csup\u003e7-11\u003c/sup\u003e Many surgical clinicians find music to be a generally favorable part of the theatre environment,\u003csup\u003e9-13\u003c/sup\u003e with music being seen as improving calmness,\u003csup\u003e7\u003c/sup\u003e stress,\u003csup\u003e14 15\u003c/sup\u003e mood,\u003csup\u003e10\u003c/sup\u003e surgeon and overall team performance,\u003csup\u003e9\u003c/sup\u003e however concerns remain over its distracting properties and risk to disrupt communication.\u003csup\u003e12 14 16 17\u003c/sup\u003e We have previously documented the challenges of investigating the effects of music on surgeon\u0026nbsp;physiological and psychological parameters\u0026nbsp;in the in-situ OR environment, due multiple confounding variables such as heterogeneity in case complexity, unexpected complications and experience of team members. An alternative approach to investigate the effect of environment on a surgeon\u0026rsquo;s experience of stress and task performance is a surgical simulation task, as this permits superior control of confounding variables and more extensive physiological monitoring.\u003csup\u003e19\u003c/sup\u003e For example, Oomens \u003cem\u003eet al\u003c/em\u003e observed that music improved task performance, instrument handling efficiency and reduced SURG-TLX parameters during a simple surgical simulation task (i.e., laparoscopic peg transfer) in medical students.\u003csup\u003e20\u003c/sup\u003e However it remains unknown if beneficial effects would be observed for tasks with a higher level of complexity and in more experienced operators.\u003c/p\u003e\n\u003cp\u003eThe objective of the present study was to conduct a randomized controlled interventional trial using a complex\u0026nbsp;simulated surgical task (i.e., carotid patch-angioplasty)\u0026nbsp;to test the primary hypothesis that music reduces an operator\u0026rsquo;s psychological and physiological stress response to a simulated surgical task. We also included a direct comparison of the effect of music on inexperienced (i.e., undergraduate medical students) versus experienced (i.e., trained surgeons) operators to extend and permit comparisons with previous research identifying that preferred music improves performance and reduces mental workload in inexperienced operators during the learning phase of a new and challenging surgical task\u003csup\u003e20-22\u003c/sup\u003e. The inclusion of such groups enhances the ecological validity of these novel investigations, while potentially informing the design of future studies examining psychophysiological stress and its mitigation in simulated surgery.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003e\u003cem\u003eEthics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe Effect of background music on STress Responses Amongst Undergraduates and Surgeons performing Simulated Surgical tasks: A randomised cross-over interventional trial (The STRAUSS study) was a non-blinded controlled crossover trial with balanced allocation carried out at the Faculty of Health and Medical Sciences, University of Auckland between April and October 2023. The STRAUSS study was designed in accordance with the CONSORT guidelines with the crossover study extension to randomised crossover trials.\u003csup\u003e23 24\u003c/sup\u003e This interventional trial was registered with the World Health Organisation International Clinical Trials Registry Platform (Universal Trial Number: U1111 1288-7255, 20/02/2023), the Australia and New Zealand Clinical Trials Registry (ANZCTR reference: ACTRN12623000306617, 20/3/2023) and was approved by the New Zealand Health and Disability Ethics Committee (HDEC 20/CEN/57) and conformed to the standards in the Declaration of Helsinki (2013). All participants provided explicit written informed consent prior to commencement.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEligible participants were undergraduate medical students (inexperienced/MS) and senior vascular trainee surgeons or vascular consultant surgeons (experienced/VS). Participants were excluded if they had a significant physical impairment that inhibited dextrous task completion, current pregnancy, a significant cardiac history, or a hearing impairment in which the auditory perception of music was not possible. Participants were asked to refrain from caffeine, cardioactive medications and strenuous exercise 12 hours prior to the study. Each participant had anthropometric and demographic information gathered.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTrial Protocol and Randomisation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were in the seated position with a table in front of them. After at least 5 minutes at rest, baseline physiological (5 minutes) and psychological measures were recorded. Using a Vascular Micro-Surgery Head Simulator (More Than Simulators\u0026trade;, Barcelona, Spain), participants were asked to perform a patch-angioplasty anastomosis using a double armed 5-0 prolene suture and a bovine pericardial patch (Xenosure\u0026trade;, Le Maitre) to a 1.5 cm long arterial defect in \u0026nbsp;a 6 mm bio-synthetic tubegraft (Omniflow \u0026trade;, Le Maitre) that served as a carotid artery (Figure 1). MS participants each had a period of initial training in which they were shown a five-minute video of a patch-angioplasty anastomosis and then were trained to perform the task on the model by the researcher (A.N.). VS participants were allowed to perform the task once to familiarise themselves with the surgical model during the training phase. All participants were then instructed to perform the surgical task a total of four times, randomised (by coin toss) to music or a no-music control using a block of size two. This ensured that each participant performed the task twice under each condition, once each in the first half and second half of the protocol. Participants were instructed to perform the task as neatly and quickly as possible, and an researcher observed their work while taking notes on a clipboard. A camera was set up in the corner of the room, focused on the participants hands. After the training period and after each task was completed, there was a rest period of approximately five-minutes (Figure 1). Participants started from a resting position, and the task was considered complete when they had trimmed the final knot. Blinding was not possible with this study design, so allocation concealment was utilised. Participants were informed of the allocation at the time of commencement of the task and were kept blinded to the randomisation method. The intervention was participant selected music, with a choice of playlist, artist, or genre radio from Spotify\u0026trade;. The no-music control condition was a recorded sound clip of ambient theatre noise.\u003csup\u003e25\u003c/sup\u003e Both conditions were played through noise cancelling headphones at a medium volume acceptable to the participant.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eExperimental Measures\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary performance outcome measures were time to task completion, number of errors, self-rated performance on the Global Rating Scale\u003csup\u003e26\u003c/sup\u003e and two anastomotic quality scales: The 10-point Microsurgical Anastomosis Rating Scale (MARS10)\u003csup\u003e27\u003c/sup\u003e the End-Product Rating Scale (EPRS).\u003csup\u003e28\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePrimary psychological outcome measures were the Six-Item State Trait Anxiety Inventory (STAI-6) and a Surgical Taskload Index (SURG-TLX) completed at baseline and immediately on task completion after each of the four trials. The STAI-6 has reported strong internal reliability, to be highly correlated with the full STAI, and it has been used in many healthcare settings.\u003csup\u003e29-31\u003c/sup\u003e Each component of the STAI-6 could possibly score between 1 and 4, with a minimum total score of 6 and maximum score of 24.\u003csup\u003e32\u003c/sup\u003e The SURG-TLX is a multidimensional, surgery-specific workload measure that was developed and validated specifically for use in surgery from the NASA Task-load Index.\u003csup\u003e33\u003c/sup\u003e The highest possible score for the total SURG-TLX is 126, and the minimum score is 6, with each of 6 domains scored between 1 and 21.\u003csup\u003e33\u003c/sup\u003e A higher score represents higher task-load.\u003c/p\u003e\n\u003cp\u003eParticipants were instrumented for continuous monitoring of heart rate (HR) by a lead II electrocardiogram (BioAmp, FE231, ADInstruments, Bella Vista, NSW, Australia) and intermittent monitoring of blood pressure by an automated digital sphygmomanometer fixed to the left upper arm (HEM-7121, Omron Healthcare, Kyoto Japan) (Figure 1). Mean arterial pressure (MAP) was calculated post-hoc. Respiratory frequency (R\u003cem\u003ef\u003c/em\u003e) and partial pressure of end-tidal carbon dioxide (P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e) were monitored continuously via a single-nostril nasal cannula using a gas analyzer (Respiratory Gas Analyzer, ML206, ADInstruments) calibrated using standard gases. Middle cerebral artery mean blood velocity (MCA Vm) was measured by transcranial Doppler ultrasonography (ST3, Spencer Technologies, Redmond, WA, USA). Blood velocity in the M1 segment of the middle cerebral artery was measured using a 2 MHz probe fixed over the temporal window with an adjustable headband. The M1 segment was identified using search techniques described elsewhere (Aaslid et al., 1982; Willie et al., 2011).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eRaw signals underwent analog-to-digital conversion at 1 kHz (Powerlab and LabChart v8; ADInstruments) and were stored for offline analysis. From the ECG, HR was calculated on a beat-to-beat basis. Breath-by-breath R\u003cem\u003ef\u003c/em\u003e and P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e were obtained, and artefacts were removed. Raw physiological responses were averaged over a 1-minute period at \u003cu\u003efour\u003c/u\u003e timepoints: \u003cu\u003erest\u003c/u\u003e (\u003cem\u003e3 minutes prior to task commencement\u003c/em\u003e), the \u003cu\u003estart\u003c/u\u003e of the task (\u003cem\u003eimmediately after commencement)\u003c/em\u003e, the isometric \u003cu\u003emidpoint\u003c/u\u003e of the task, and the \u003cu\u003eend\u003c/u\u003e of the task (\u003cem\u003eimmediately prior to completion\u003c/em\u003e). R-R intervals were extracted from ECG data over a 5-minute period at the overall resting \u003cu\u003ebaseline\u003c/u\u003e and the isometric \u003cu\u003emidpoint\u003c/u\u003e of the task and subsequently analysed in line with the European Society of Cardiology (ESC) and the North America Society of Pacing and Electrophysiology standards of measurement of heart rate variability.\u003csup\u003e34\u003c/sup\u003e The ECG data were independently assessed and verified to exclude any artefacts, pauses, ectopics, and analysis was performed using HRV software (Kubios, Finland) with medium beat correction.\u003csup\u003e35\u003c/sup\u003e Time domain: RMSSD (square root of the mean of the sum of the squares of differences between adjacent NN intervals), frequency domain: LF:HF ratio (HF, high frequency [0.15 \u0026ndash; 0.4 Hz]; LF, low frequency [0.04 \u0026ndash; 0.15 Hz]) and composite scores of the parasympathetic nervous system (PNS), sympathetic nervous system (SNS) and Baevsky\u0026rsquo;s stress indices were reported.\u003csup\u003e35 36\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical Analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBased on our previous work showing that mean operative SURG-TLX amongst surgeons was 48\u0026plusmn;22, it was estimated that a total of 20 participants would be sufficient to detect a 30% difference between music and control conditions. Normality was assessed visually and with QQ plots. Performance outcomes were summarised and compared between trial arms with a two-tailed paired t-test. Psychological and HRV outcomes were compared with a two-way repeated measures ANOVA with group (MS, VS) and condition (baseline, music, control) as the main effects. Physiological outcomes were compared using three-way repeated measures ANOVA with group (MS, VS), condition (music, control), and time (baseline, start, midpoint, end) as main effects. Tukey\u0026rsquo;s test was used for post-hoc analysis of significant main effects and interactions. Statistical significant was accepted at p\u0026lt;0.05. Pairwise deletion was used for missing data. Data are presented as mean \u0026plusmn; standard deviation unless otherwise stated. Statistical analysis was carried out using R and R Studio (v2022.07.0)\u003csup\u003e37\u003c/sup\u003e and GraphPad Prism version 10.0.0 for Windows (GraphPad Software, Boston, Massachusetts USA).\u003csup\u003e38\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cem\u003eProtocol adherence\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe protocol was well tolerated. All MS participants were able to learn and perform the surgical tasks, and all participants completed the protocol. The music intervention and control conditions did not need to be turned off for any participant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipant Characteristics\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe MS group (n=15) were aged 23\u0026plusmn;2.7 years (mean\u0026plusmn;SD), with a height and weight of 170\u0026plusmn;10 cm and 67\u0026plusmn;21 kg, respectively. Ten (67%) were female and five (33%) were students who were in the first three university-based years of the undergraduate degree, and the remaining were in their final three hospital-based years. The pop genre was the most popular choice of the music intervention (n=4), although choices also included classical, Rhythm and blues, atmospheric instrumental, jazz and metal. The VS group (n=12) were older (42\u0026plusmn;10 years; p\u0026lt;0.0001 vs. MS), taller (179\u0026plusmn;8 cm; p=0.01), heavier (81\u0026plusmn;12 kg; p=0.04) and more likely to be male (p\u0026lt;0.01). There was 1 female participant and 8 were consultant surgeons. The most popular choices in the VS group \u0026nbsp;were pop, easy listening and 80s music equally \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSurgical Performance\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure 2 illustrates the mean performance measures for the surgical task. Significant group effects were observed for time to completion (F(1,25)=43.4, p\u0026lt;0.0001), errors (F(1,25)=28.9, p\u0026lt;0.0001), and global rating scale (F(1,25)=16.4, p=0.0004). The VS cohort (mean difference of main effect, 95% CI) were faster to complete the task (-10 minutes [-13.2 - -6.8]), made fewer errors (-4 [-7 - -3]) and had higher self-rated scores (6 [2-9]). Music did not affect time to completion, number of errors or global rating scale (i.e., no condition effect was observed).\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychological Responses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSURG-TLX total score and STAI-6 total score for baseline, music, and control (condition main effect) for MS and VS (group main effect) are shown in Figure 3 and Table 2. There was an interaction between condition and group for SURG-TLX total score (F(2,50) = 12.36, p\u0026lt;0.0001). MS exhibited pronounced increases from baseline by D40 [26-55, p\u0026lt;0.0001] with music, and by D44 [31-57, p\u0026lt;0.0001] with control, that tended to be greater than VS who exhibited increases from baseline by D17 [7-28, p\u0026lt;0.01] in music and by D17 [8-27, p\u0026lt;0.01] in control. SURG-TLX total score was not different between music and control in either group (MS p=0.392 VS p=1.000). A significant main effect of condition was noted for STAI-6 total scores (F(1.9,48.3)=18.7, P\u0026lt;0.0001), with an increase from baseline to control (D3 [1.7-4.3], p\u0026lt;0.0001) and baseline to music (D3 [1.4-4.3], p=0.0001), but no difference observed between music and control (-0.15 [-1.4-1.1], p=0.955).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysiological Responses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFigure 4 demonstrates the HR, MCA Vm, P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e, and RR responses to the surgical task at four timepoints (rest, start, midpoint and end; time main effect), in MS and VS (group main effect), for music and no music (condition main effect). HR increased from baseline at all timepoints (time main effect; F(3,75)=14.2, p\u0026lt;0.0001) and reached a peak at the end of the task (D5.1bpm [3.0-7.1] vs. baseline, p\u0026lt;0.0001). HR was lower in VS (group main effect; F(1,25)=14.8, p=0.0007) but was not affected by music (condition main effect; p=0.204). Similarly, MCA Vm was increased from baseline at all timepoints during the task (time main effect; F(3,75)=36.8, p\u0026lt;0.0001) and was lower in VS (group main effect; F(1,25)=9.2, p=0.006), but was not affected by music (condition main effect; F(1,25)=3.0, p=0.094). P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e increased during the task (time main effect; F(3,75)=15.8, p\u0026lt;0.0001) reaching a peak at the midpoint (+1.5 [0.95-2.1] mmHg, p\u0026lt;0.0001), and overall was lower with music (condition main effect; F(1,25)=5.0, p=0.034). RR increased only at the end of the task (time main effect; F(3,75)=2.9, p=0.040; +1.7 [0.3-3.0] bpm vs baseline, p\u0026lt;0.01). MAP was higher in VS than MS (group main effect; F(1,25)=6.0, p=0.022), although not different between conditions (condition main effect; F(1,25)=0.05, p=0.822).\u003cem\u003e\u003cs\u003e\u003c/s\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eHRV Responses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHRV parameters for the baseline, music, and control conditions, in the MS and VS groups, are shown in Table 1 and Figure 5. For PNS Index, there was a main effect of condition (F(1.1,27.8)=17.5, p=0.0002). with PNS Index being lower than baseline in both control (-0.45 [-0.73 - -0.18], p\u0026lt;0.0009) and music (-0.57 [-0.91 - -0.23], p\u0026lt;0.0009), and lower in music than control (-0.11 [-0.22 - -0.008], p=0.032). There was also a main effect of group (F(1,25)=5.9, p=0.023), such that MS had a lower PNS index (-0.8 [-1.5- -0.12]) than VS. There was a main effect of condition (F(1.1,28.3)=12.6, p=0.001) for SNS Index with values being higher than baseline during both control (0.54 [0.96 \u0026ndash; 0.13], p\u0026lt;0.009) and music (0.68 [0.22 \u0026ndash; 1.14], p\u0026lt;0.003), and higher during music than control (0.14 [0.004 \u0026ndash; 0.27], p=0.042). SNS index was higher in MS than VS (group main effect F(1,25)=6.2, p=0.019;\u0026nbsp;D+1.0 [0.17-1.8]).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was a main effect of condition for RMSSD (F(1.2, 30.2)=5.6, p=0.020), with a tendency for a decrease from baseline during music (-5.98 [-12.4-0.48], p=0.073) and control (-3.72 [-8.9-1.4], p=0.192), and lower values during music than control (-2.3 [-4.7-0.24], p=0.081). Total power also exhibited a main effect of condition (F(1.3,32.3)=3.9, p=0.046), with lower values in music than control (-322 [-624 - -20], p=0.035). There was a main effect of condition for high frequency parameters (F(1.3,32.2)=4.2, p=0.038), though no significant results on post-hoc analysis. There were no significant main effects or interactions noted for low frequency power and LF/HF ratio, while there was an interaction between condition and group for Baevsky\u0026rsquo;s stress index (F(2,50)=3.6, p=0.035), although no significant post hoc differences were observed.\u0026nbsp;\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis study examined the effect of background music on performance, and the psychological and physiological responses to a complex simulated surgical task under stressful circumstances. The five major novel findings were, 1) music did not affect either the speed or accuracy of the simulated surgical stress task performance, 2) the task increased subjective ratings of anxiety and task load but these were unaffected by music, 3) HR, MCA Vm, P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e, RR, and SNS index were increased, while PNS index decreased during the task, indicative of a physiological stress response, 4) PNS index was reduced and SNS index was increased in the presence of music suggestive of an arousal response, and finally 5) the more experienced group (VS) performed faster, with fewer errors and greater self-rating than the inexperienced (MS) group, and had overall lower HR, MCA Vm and MAP, but there were no psychological or physiological differences between VS and MS in their responses to music.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTask Performance\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA beneficial effect of music on simulated surgical task performance was not demonstrated in the present study in either inexperienced (MS) or experienced (VS) operators. This is out of keeping with El Boghdady\u0026rsquo;s systematic review that concluded classical music at a low to medium volume improves accuracy and speed, and outweighs negative effects of distractedness, on the basis of n=18 studies that were predominantly simulation studies and surveys.\u003csup\u003e39\u003c/sup\u003e This may in part be due to the novel use of a complex, non-laparoscopic surgical model of carotid patch-plasty in this field of research, a task that required the performance of multiple surgical steps (i.e. knot tying, suturing, patch trimming) which may take variable lengths of time. To investigate this variable, future research may consider utilising a study design that includes a complex multi-step task in comparison to a simple task. Music has also been shown to hasten the learning process of surgical tasks on the Da Vinci robot.\u003csup\u003e21\u003c/sup\u003e In the present study, there was no music or sound during the training phase of the protocol, and future research could investigate the effect of music on the learning trajectory of complex surgical tasks and speed of skill acquisition.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePsychological Stress\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eDuring task performance, SURG-TLX scores increased to a mean of 64 for MS and 47 for VS. SURG-TLX scores of this magnitude during tasks are similar to that observed in surgeons performing cardiac surgery (SURG-TLX= 48 points) or breast and vascular surgery (48 points), with scores over 50-55 points associated with increased risk of error.\u003csup\u003e18 40-42\u003c/sup\u003e Despite the simulated carotid patch-angioplasty task inducing a clear stress response from operators, this was not modified by music in either the VS or MS group.\u003c/p\u003e\n\u003cp\u003eBackground music decreased workload scores in two previous studies of inexperienced operators performing simulated laparoscopic surgery\u003csup\u003e19 20\u003c/sup\u003e The possible reasons for the conflicting findings of the present study include the nature of the control condition (silence vs. ambient OR noise) and the nature of simulated task. SURG-TLX measured reproducible changes from baseline in the participants in this study. Other authors have preliminary recommended the SURG-TLX as a standard measure to assess operators\u0026rsquo; experience in studies of surgical innovation, as it has been found to be most relevant, comprehensive, and comprehensible.\u003csup\u003e43\u003c/sup\u003e STAI-6 scores increased during task performance (around 3 points in both groups), though the level of experience did not affect this increase. STAI-6 has been frequently used validated scale for stress measurement and has successfully been demonstrated to correlate to LF/HF though a direct comparison between STAI-6 and SURG-TLX has yet to be published.\u003csup\u003e44\u003c/sup\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePhysiological Stress\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe data here represents the most detailed physiological phenotype of a surgeon performing a simulated task to date.\u003csup\u003e45 46\u003c/sup\u003e In other studies, during surgery, mean HR has been measured to be the most consistent biomarker elevated by 6 to 22 bpm from baseline compared to 5 bpm in this study.\u003csup\u003e46\u003c/sup\u003e In our study, there was no difference in HR between music and control conditions. Analysis of HRV has been shown to be a good objective assessment of mental stress in the surgical setting.\u003csup\u003e47\u003c/sup\u003e Notably, we observed that music reduced the PNS index and increased the SNS index, suggestive of sympathetic predominance, which is contrary to widespread perception of OR music, and previous interventional studies.\u003csup\u003e9 10 20 45\u003c/sup\u003e Further evidence for an arousal response to music is the lowering of P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u003c/sub\u003e, which would fit with an increase in minute ventilation under the music condition. Allen \u003cem\u003eet al\u003c/em\u003e suggested that self-selected music could reduce skin conductance, pulse and blood pressure and improve speed and accuracy of arithmetic tasks when compared to control music or the absence of music.\u003csup\u003e48\u003c/sup\u003e One study reported an increase in MAP between control and self-selected music,\u003csup\u003e49\u003c/sup\u003e though four other studies also demonstrated no change in HR or MAP under music conditions compared to control.\u003csup\u003e45\u003c/sup\u003e Finally, relaxing music (slow-paced classical pieces) when compared to control showed greater return to baseline in high frequency HRV after a stressing event suggesting a role for music in the recovery for surgeons after stressful operations.\u003csup\u003e50\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTranscranial Doppler ultrasound was first used by Aaslid et al\u003csup\u003e51\u003c/sup\u003e to measure cerebral blood velocity in dynamic cerebral autoregulation research, and its application to surgeons is novel. Cerebral perfusion (i.e., MCA Vm) was significantly increased during task performance, with maximal increase during the midpoint of the operation, although a difference between music and control conditions was not observed. The cerebrovascular changes during task performance reported in this study are not surprising, in that MCA Vm has been shown to increase bilaterally in mathematical cognitive effort,\u003csup\u003e52\u003c/sup\u003e and during simulated robot assisted surgery, the pre-frontal cortex (supplied by the MCA and anterior cerebral artery) differentially activates.\u003csup\u003e53-55\u003c/sup\u003e The functional hyperaemia we observed may be linked to neuronal activation during the surgical task (i.e., neurovascular coupling), but the coincident elevation in P\u003csub\u003eET\u003c/sub\u003eCO\u003csub\u003e2\u0026nbsp;\u003c/sub\u003e(a proxy for arterial CO\u003csub\u003e2\u003c/sub\u003e concentration a powerful cerebrovascular vasodilator) during task performance is also likely to be a contributory factor.\u003csup\u003e56\u003c/sup\u003e The nature of the task meant that non-invasive beat-to-beat blood pressure could not be measured using finger photoplethysmography, hence cerebral perfusion pressure estimates cannot be incorporated into the interpretation of the MCA Vm response.\u003csup\u003e57\u003c/sup\u003e It should be noted that transcranial Doppler assesses artery blood velocity, rather than blood flow, and whether the this is representative of cerebral blood flow rests on the assumption that vessel diameter remains constant. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe impact of experience\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe VS cohort were older, taller, heavier, and contained more males which may account for the baseline group main effects between groups (i.e. lower HR, lower MCA Vm, higher MAP). Unsurprisingly, the greater experience was associated with improved speed and quality of the task performance.\u003csup\u003e58 59\u003c/sup\u003e A time x group interaction in HR is suggestive of attenuated cardiovascular reactivity to the task in the VS group, for whom the surgical task would have been more familiar. This is in line with previous work that has shown senior surgeons to display a better stress management capacity and are less prone to cognitive distraction compared to junior surgeons.\u003csup\u003e60 61\u003c/sup\u003e Future work should then consider that if music were to attenuate a psychophysiological response to surgical tasks, this effect may be less detectable in an experienced population where the stress response to tasks is smaller.\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe type of music\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe question often arises as to whether the type of music is important. Self-selected music is a commonly researched music choice in the surgical setting, in part due to Allen \u003cem\u003eet al\u003c/em\u003e\u0026rsquo;s seminal paper, and was therefore used in this study.\u003csup\u003e45 48 62\u003c/sup\u003e Music considered to be unpleasant may generate poorer surgical performance, an effect which may be measurable through application of electro-encephalography.\u003csup\u003e63 64\u003c/sup\u003e Dissonance in music has been shown to induce unpleasant feelings and physiological responses which may lend support to the application of consonant music.\u003csup\u003e65\u003c/sup\u003e Furthermore, faster music may reduce OR preparation time,\u003csup\u003e66\u003c/sup\u003e increase the rate of task performance (while also increasing the number of mistakes),\u003csup\u003e67\u003c/sup\u003e greater sound intensity can increase perceived arousal and high rhythmic tension may more strongly affect heart rate variability.\u003csup\u003e68\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStrengths and Limitations\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral experimental considerations should be considered when interpreting the results of the present investigation. The crossover design was counterbalanced to minimise possible learning effects and all participants undertook a supervised training and practice period prior to being assessed to further mitigate against learning effects. To increase the experience of stress during the surgical task several experimental manipulations were employed. The Trier Social Stress Test is an ecologically valid stressor induced by public speaking, and in the present study and social evaluation was incorporated with the presence of an unresponsive yet engaged assessor and a camera setup (without filming).\u003csup\u003e69\u003c/sup\u003e Perceived time pressure refers to the sense of time pressure experienced in the absence of genuine time limits and has been shown to be an empirical stressor, and was also incorporated into the study design.\u003csup\u003e70\u003c/sup\u003e Finally, participants were asked to complete task to the highest quality possible to maintain a level of sustained mental effort investment during the protocol in an aim to increase mental workload, stress and fatigue during the task.\u003csup\u003e71\u003c/sup\u003e The results indicate that the task and the applied manipulation were successful in generating a stress response. It is rarely silent in a working operating room, thus ambient theatre noise was selected as the control condition.\u003csup\u003e72\u003c/sup\u003e As such it is possible that previous work showing that music improved simulated laparoscopy compared to a no music / silence control may be due to the presence of auditory stimulation (or the absence of silence), rather than the music itself.\u003csup\u003e20\u003c/sup\u003e\u0026nbsp; \u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe observed that the performance of a simulated carotid patch-angioplasty under stressing conditions successfully increased markers of psychological and physiological stress in both inexperienced and experienced operators. Despite previous research identifying generally positive surgeon perceptions, background music did not improve either surgical task performance or attenuate subjective ratings of task load and anxiety, but in fact evoked additional physiological arousal evidenced by decreased PNS index and increased SNS index. As expected, the more experienced group performed faster and more accurately than the inexperienced group, but there were no psychological or physiological differences in their responses to music.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank Dr Michael Plunkett, Thalia Babbage, Dr Ana Sayegh, Dr Mickey Fan and Harvey Walsh from the University of Auckland Human Cardiovascular Physiology Lab for their assistance with data collection, Dr Alana Cavadino for biostatistical support, Lois Blackwell and Nicky Cockrem for administrative support, the University of Auckland Clinical Research Centre and all the surgeons and students that participated in the protocol. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis interventional trial was registered with the World Health Organisation International Clinical Trials Registry Platform (Universal Trial Number: U1111 1288-7255) and the Australia New Zealand Clinical Trials Registry (ANZCTR reference: ACTRN12623000306617). Ethics approval was granted by the New Zealand Health and Disability Ethics Committee (HDEC 20/CEN/57 2023 AM 9287).\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this work was received from The Specialty Trainees of New Zealand (STONZ) Research Grant, The Australian and New Zealand Society for Vascular Surgery and The Royal Australasian College of Surgeons Aotearoa New Zealand Research Scholarship. The materials used in the surgical model (Omniflow\u0026trade; and Xenosure\u0026trade;) were kindly donated by LeMaitre Vascular Ltd. LeMaitre had no input or oversight at any stage during the trial and did not contribute to the project in any other way.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due participant confidentiality but de-identified and anonymous data are available from the corresponding author upon reasonable request.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no conflicts of interest to declare.\u003cem\u003e\u003cbr\u003e\u003c/em\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAN: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review \u0026amp; Editing, Visualization, Supervision, Project administration, Funding acquisitionMK: Conceptualization, Methodology, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review \u0026amp; Editing, Visualization, Supervision, Project administration, Funding acquisition, JPF: Conceptualization, Methodology, Software, Formal analysis, Investigation, Resources, Data Curation, Writing - Original Draft, Writing - Review \u0026amp; Editing, Supervision, Project administration, Funding acquisition. All authors reviewed the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eArora S, Flindall I, Youngson GG. Performance-shaping factors. In: Flin R, Youngson GG, Yule S, eds. Enhancing surgical performance: A primer in non-technical skills: CRC press 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArora S, Hull L, Sevdalis N, et al. Factors compromising safety in surgery: stressful events in the operating room. American journal of surgery 2010;199(1):60\u0026ndash;5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjsurg.2009.07.036\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2009.07.036\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2010/01/28]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArora S, Sevdalis N, Nestel D, et al. The impact of stress on surgical performance: a systematic review of the literature. \u003cem\u003eSurgery\u003c/em\u003e 2010;147(3):318\u0026thinsp;\u0026ndash;\u0026thinsp;30, 30 e1-6. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.surg.2009.10.007\u003c/span\u003e\u003cspan address=\"10.1016/j.surg.2009.10.007\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2009/12/17]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharma A, Sharp DM, Walker LG, et al. Stress and burnout in colorectal and vascular surgical consultants working in the UK National Health Service. Psychooncology 2008;17(6):570\u0026ndash;6. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/pon.1269\u003c/span\u003e\u003cspan address=\"10.1002/pon.1269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2007/10/16]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShanafelt TD, Balch CM, Bechamps GJ, et al. Burnout and career satisfaction among American surgeons. Ann Surg 2009;250(3):463\u0026ndash;71. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/SLA.0b013e3181ac4dfd\u003c/span\u003e\u003cspan address=\"10.1097/SLA.0b013e3181ac4dfd\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2009/09/05]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eErestam S, Bock D, Andersson AE, et al. The perceived benefit of intraoperative stress modifiers for surgeons: an experimental simulation study in volunteers. Patient safety in surgery 2021;15(1):23. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13037-021-00294-6\u003c/span\u003e\u003cspan address=\"10.1186/s13037-021-00294-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2021/05/31]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUllmann Y, Fodor L, Schwarzberg I, et al. The sounds of music in the operating room. Injury 2008;39(5):592\u0026ndash;7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.injury.2006.06.021\u003c/span\u003e\u003cspan address=\"10.1016/j.injury.2006.06.021\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2006/09/23]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawksworth C, Asbury AJ, Millar K. Music in theatre: not so harmonious. A survey of attitudes to music played in the operating theatre. Anaesthesia 1997;52(1):79\u0026ndash;83. [published Online First: 1997/01/01]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarayanan A, Gray AR. First, do no harmony: an examination of attitudes to music played in operating theatres. New Zealand Medical Journal 2018;131(1480):68\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarayanan A, Naidoo M, Kong VY, et al. Broad responses and attitudes to having music in surgery (the BRAHMS study) - a South African perspective. South African journal of surgery Suid-Afrikaanse tydskrif vir chirurgie 2023;61(1):30\u0026ndash;38. [published Online First: 2023/04/14]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarayanan A, Naidoo M, Kong V, et al. Broad Responses and Attitudes to Having Music in Surgery (The BRAHMS Study): An Australia and Aotearoa New Zealand Perspective. Surgery Open Science 2024;17:30\u0026ndash;34. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.sopen.2023.12.009\u003c/span\u003e\u003cspan address=\"10.1016/j.sopen.2023.12.009\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFaraj AA, Wright P, Haneef JH, et al. LISTEN WHILE YOU WORK? The Attitude of Healthcare Professionals to Music in the OR. Ornac J 2015;33(2):31\u0026ndash;2, 34\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu VX, Oomens P, Merkus N, et al. The Perception and Attitude Toward Noise and Music in the Operation Room: A Systematic Review. Journal of Surgical Research 2021;263:193\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMakama JG, Ameh EA, Eguma SA. Music in the operating theatre: opinions of staff and patients of a Nigerian teaching hospital. Afr Health Sci 2010;10(4):386\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorge S, Ahmed S, Mammen KJ, et al. Influence of music on operation theatre staff. Journal of Anaesthesiology Clinical Pharmacology 2011;27(3):354\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWay TJ, Long A, Weihing J, et al. Effect of noise on auditory processing in the operating room. Journal of the American College of Surgeons 2013;216(5):933\u0026ndash;8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jamcollsurg.2012.12.048\u003c/span\u003e\u003cspan address=\"10.1016/j.jamcollsurg.2012.12.048\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2013/03/23]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheriyan S, Mowery H, Ruckle D, et al. The Impact of Operating Room Noise Upon Communication During Percutaneous Nephrostolithotomy. J Endourol 2016;30(10):1062\u0026ndash;66. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1089/end.2016.0498\u003c/span\u003e\u003cspan address=\"10.1089/end.2016.0498\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2016/08/25]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarayanan A, Fisher JP, Khashram M. The MOSART Study - The effect of Music on the Operating Surgeon \u0026ndash; A Randomised Trial. In: ANZSVS, ed. Australia and New Zealand Society of Vascular Surgery - Annual Scientific Conference. Gold Coast, Australia, 2021.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu VX, Oomens P, Kleinrensink VEE, et al. The effect of preferred music on mental workload and laparoscopic surgical performance in a simulated setting (OPTIMISE): a randomized controlled crossover study. Surgical Endoscopy 2020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOomens P, Fu VX, Kleinrensink VE, et al. The Effects of Preferred Music on Laparoscopic Surgical Performance: A Randomized Crossover Study. World journal of surgery 2020:1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSiu KC, Suh IH, Mukherjee M, et al. The effect of music on robot-assisted laparoscopic surgical performance. Surgical innovation 2010;17(4):306\u0026ndash;11. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1553350610381087\u003c/span\u003e\u003cspan address=\"10.1177/1553350610381087\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2010/09/08]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGil K, Jones M, Mouw T, et al. Satisfaction or Distraction: Exposure to Nonpreferred Music May Alter the Learning Curve for Surgical Trainees. Journal of surgical education 2020;77(6):1370\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchulz KF, Altman DG, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.c332\u003c/span\u003e\u003cspan address=\"10.1136/bmj.c332\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2010/03/25]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDwan K, Li T, Altman DG, et al. CONSORT 2010 statement: extension to randomised crossover trials. BMJ 2019;366:l4378. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/bmj.l4378\u003c/span\u003e\u003cspan address=\"10.1136/bmj.l4378\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmbience Laboratory. Surgery Background Sounds 2. ASMR Ambience Hospital Youtube2022 [Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.youtube.com/watch?v=s4HyneDVXi0\u003c/span\u003e\u003cspan address=\"https://www.youtube.com/watch?v=s4HyneDVXi0\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoyle JD, Webber EM, Sidhu RS. A universal global rating scale for the evaluation of technical skills in the operating room. American journal of surgery 2007;193(5):551\u0026ndash;5; discussion 55. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjsurg.2007.02.003\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2007.02.003\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2007/04/17]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStogowski P, Fliciński F, Białek J, et al. Microsurgical Anastomosis Rating Scale (MARS10): A Final Product Scoring System for Initial Microsurgical Training. Plast Surg (Oakv) 2021;29(4):243\u0026ndash;49. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/2292550320969649\u003c/span\u003e\u003cspan address=\"10.1177/2292550320969649\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2021/11/12]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrice J, Naik V, Boodhwani M, et al. A randomized evaluation of simulation training on performance of vascular anastomosis on a high-fidelity in vivo model: The role of deliberate practice. The Journal of Thoracic and Cardiovascular Surgery 2011;142(3):496\u0026ndash;503. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jtcvs.2011.05.015\u003c/span\u003e\u003cspan address=\"10.1016/j.jtcvs.2011.05.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarteau TM, Bekker H. The development of a six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI). The British journal of clinical psychology 1992;31(3):301\u0026ndash;6. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.2044-8260.1992.tb00997.x\u003c/span\u003e\u003cspan address=\"10.1111/j.2044-8260.1992.tb00997.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 1992/09/01]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCourt H, Greenland K, Margrain T. Measuring Patient Anxiety in Primary Care: Rasch Analysis of the 6-item Spielberger State Anxiety Scale. Value in health: the journal of the International Society for Pharmacoeconomics and Outcomes Research 2010;13:813\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1524-4733.2010.00758.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1524-4733.2010.00758.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBayrampour H, McDonald S, Fung T, et al. Reliability and validity of three shortened versions of the State Anxiety Inventory scale during the perinatal period. Journal of psychosomatic obstetrics and gynaecology 2014;35(3):101\u0026ndash;7. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3109/0167482x.2014.950218\u003c/span\u003e\u003cspan address=\"10.3109/0167482x.2014.950218\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2014/08/16]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChlan L, Savik K, Weinert C. Development of a shortened state anxiety scale from the Spielberger State-Trait Anxiety Inventory (STAI) for patients receiving mechanical ventilatory support. Journal of nursing measurement 2003;11(3):283\u0026ndash;93. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1891/jnum.11.3.283.61269\u003c/span\u003e\u003cspan address=\"10.1891/jnum.11.3.283.61269\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2005/01/07]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilson MR, Poolton JM, Malhotra N, et al. Development and validation of a surgical workload measure: the surgery task load index (SURG-TLX). World journal of surgery 2011;35(9):1961\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-011-1141-4\u003c/span\u003e\u003cspan address=\"10.1007/s00268-011-1141-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2011/05/21]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEuropean Society of Cardiology. Heart rate variability: standards of measurement, physiological interpretation and clinical use. Task Force of the European Society of Cardiology and the North American Society of Pacing and Electrophysiology. Circulation 1996;93(5):1043\u0026ndash;65. [published Online First: 1996/03/01]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTarvainen MP, Niskanen JP, Lipponen JA, et al. Kubios HRV\u0026ndash;heart rate variability analysis software. Computer methods and programs in biomedicine 2014;113(1):210\u0026ndash;20. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.cmpb.2013.07.024\u003c/span\u003e\u003cspan address=\"10.1016/j.cmpb.2013.07.024\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2013/09/24]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMethodical Recommendations\u0026mdash;Use Kardivar System for Determination of the Stress Level and Estimation of the Body Adaptability-Standards of Measurements and Physiological Interpretation.; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eR: A Language and Environment for Statistical Computing [program]. Vienna, Austria: R Foundation for Statistical Computing, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePrism G. GraphPad Prism. GraphPad Software Inc 2020\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEl Boghdady M, Ewalds-Kvist BM. The influence of music on the surgical task performance: A systematic review. \u003cem\u003eInternational journal of surgery (London, England)\u003c/em\u003e 2020;73:101\u0026thinsp;\u0026ndash;\u0026thinsp;12. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijsu.2019.11.012\u003c/span\u003e\u003cspan address=\"10.1016/j.ijsu.2019.11.012\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2019/11/25]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKennedy-Metz LR, Wolfe HL, Dias RD, et al. Surgery Task Load Index in Cardiac Surgery: Measuring Cognitive Load Among Teams. Surgical innovation 2020;27(6):602\u0026ndash;07. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1553350620934931\u003c/span\u003e\u003cspan address=\"10.1177/1553350620934931\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYu D, Lowndes B, Thiels C, et al. Quantifying Intraoperative Workloads Across the Surgical Team Roles: Room for Better Balance? World journal of surgery 2016;40(7):1565\u0026ndash;74. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00268-016-3449-6\u003c/span\u003e\u003cspan address=\"10.1007/s00268-016-3449-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2016/03/10]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMazur LM, Mosaly PR, Jackson M, et al. Quantitative assessment of workload and stressors in clinical radiation oncology. International journal of radiation oncology, biology, physics 2012;83(5):e571-6. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ijrobp.2012.01.063\u003c/span\u003e\u003cspan address=\"10.1016/j.ijrobp.2012.01.063\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2012/04/17]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcNair AGK, Hoffmann C, Macefield RC, et al. A standardized measurement instrument was recommended for evaluating operator experience in complex healthcare interventions. Journal of Clinical Epidemiology 2023;153:55\u0026ndash;65. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.jclinepi.2022.10.006\u003c/span\u003e\u003cspan address=\"10.1016/j.jclinepi.2022.10.006\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTj\u0026oslash;nn\u0026aring;s MS, Guzm\u0026aacute;n-Garc\u0026iacute;a C, S\u0026aacute;nchez-Gonz\u0026aacute;lez P, et al. Stress in surgical educational environments: a systematic review. BMC Med Educ 2022;22(1):791. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12909-022-03841-6\u003c/span\u003e\u003cspan address=\"10.1186/s12909-022-03841-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2022/11/17]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNarayanan A, Pearson L, Fisher JP, et al. The effect of background music on stress in the operating surgeon: scoping review. BJS Open 2022;6(5) doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/bjsopen/zrac112\u003c/span\u003e\u003cspan address=\"10.1093/bjsopen/zrac112\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBudden A, Song S, Henry A, et al. A systematic review of biological changes in surgeons\u0026rsquo; acute stress levels during surgery. Surgery in Practice and Science 2023;13:100174. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.sipas.2023.100174\u003c/span\u003e\u003cspan address=\"10.1016/j.sipas.2023.100174\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe AF, Reijmerink I, van der Laan M, et al. Heart rate variability as a measure of mental stress in surgery: a systematic review. Int Arch Occup Environ Health 2020;93(7):805\u0026ndash;21. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00420-020-01525-6\u003c/span\u003e\u003cspan address=\"10.1007/s00420-020-01525-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2020/03/28]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen K, Blascovich J. Effects of music on cardiovascular reactivity among surgeons. Jama 1994;272(11):882\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMitta N, Jayakumar V, Dhanpal N, et al. Surgical Notes: To Play or Not to Play. World journal of surgery 2019;43(11):2740\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaccarani A, Donnadieu S, Pellissier S, et al. Relaxing effects of music and odors on physiological recovery after cognitive stress and unexpected absence of multisensory benefit. Psychophysiology 2023;60(7):e14251. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/psyp.14251\u003c/span\u003e\u003cspan address=\"10.1111/psyp.14251\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAaslid R, Markwalder TM, Nornes H. Noninvasive transcranial Doppler ultrasound recording of flow velocity in basal cerebral arteries. Journal of neurosurgery 1982;57(6):769\u0026ndash;74. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3171/jns.1982.57.6.0769\u003c/span\u003e\u003cspan address=\"10.3171/jns.1982.57.6.0769\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 1982/12/01]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMontoro CI, Duschek S, Reyes del Paso GA. Variability in cerebral blood flow velocity at rest and during mental stress in healthy individuals: Associations with cardiovascular parameters and cognitive performance. Biological Psychology 2018;135:149\u0026ndash;58. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.biopsycho.2018.04.005\u003c/span\u003e\u003cspan address=\"10.1016/j.biopsycho.2018.04.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIzzetoglu K, Aksoy ME, Agrali A, et al. Studying Brain Activation during Skill Acquisition via Robot-Assisted Surgery Training. Brain sciences 2021;11(7) doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/brainsci11070937\u003c/span\u003e\u003cspan address=\"10.3390/brainsci11070937\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2021/08/07]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePatel R, Suwa Y, Kinross J, et al. Neuroenhancement of surgeons during robotic suturing. Surgical endoscopy 2022;36(7):4803\u0026ndash;14. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-021-08823-1\u003c/span\u003e\u003cspan address=\"10.1007/s00464-021-08823-1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2021/11/02]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHannah TC, Turner D, Kellner R, et al. Neuromonitoring Correlates of Expertise Level in Surgical Performers: A Systematic Review. Frontiers in human neuroscience 2022;16:705238. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fnhum.2022.705238\u003c/span\u003e\u003cspan address=\"10.3389/fnhum.2022.705238\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2022/03/08]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePurkayastha S, Sorond F. Transcranial Doppler ultrasound: technique and application. Seminars in neurology 2012;32(4):411\u0026ndash;20. doi: 10.1055/s-0032-1331812 [published Online First: 2013/01/31]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFan J-L, Nogueira RC, Brassard P, et al. Integrative physiological assessment of cerebral hemodynamics and metabolism in acute ischemic stroke. Journal of Cerebral Blood Flow \u0026amp; Metabolism 2022;42(3):454\u0026ndash;70. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0271678x211033732\u003c/span\u003e\u003cspan address=\"10.1177/0271678x211033732\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRothbaum DL, Roy J, Hager GD, et al. Task Performance in Stapedotomy: Comparison Between Surgeons of Different Experience Levels. Otolaryngology\u0026ndash;Head and Neck Surgery 2003;128(1):71\u0026ndash;77. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1067/mhn.2003.13\u003c/span\u003e\u003cspan address=\"10.1067/mhn.2003.13\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoukas C, Gazis A, Kanakis MA. Surgical Performance Analysis and Classification Based on Video Annotation of Laparoscopic Tasks. JSLS: Journal of the Society of Laparoendoscopic Surgeons 2020;24(4) doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.4293/jsls.2020.00057\u003c/span\u003e\u003cspan address=\"10.4293/jsls.2020.00057\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2020/11/05]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMarrelli M, Gentile S, Palmieri F, et al. Correlation between Surgeon's experience, surgery complexity and the alteration of stress related physiological parameters. PLoS One 2014;9(11):e112444. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0112444\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0112444\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2014/11/08]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHsu KE, Man FY, Gizicki RA, et al. Experienced surgeons can do more than one thing at a time: effect of distraction on performance of a simple laparoscopic and cognitive task by experienced and novice surgeons. Surgical endoscopy 2008;22(1):196\u0026ndash;201. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-007-9452-0\u003c/span\u003e\u003cspan address=\"10.1007/s00464-007-9452-0\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOomens P, Fu VX, Kleinrensink VEE, et al. The Effects of Preferred Music on Laparoscopic Surgical Performance: A Randomized Crossover Study. World journal of surgery 2020;44(8):2614\u0026ndash;19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMiskovic D, Rosenthal R, Zingg U, et al. Randomized controlled trial investigating the effect of music on the virtual reality laparoscopic learning performance of novice surgeons. Surgical endoscopy 2008;22(11):2416\u0026ndash;20. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00464-008-0040-8\u003c/span\u003e\u003cspan address=\"10.1007/s00464-008-0040-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2008/07/16]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSammler D, Grigutsch M, Fritz T, et al. Music and emotion: Electrophysiological correlates of the processing of pleasant and unpleasant music. Psychophysiology 2007;44(2):293\u0026ndash;304. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1469-8986.2007.00497.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1469-8986.2007.00497.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDellacherie D, Roy M, Hugueville L, et al. The effect of musical experience on emotional self-reports and psychophysiological responses to dissonance. Psychophysiology 2011;48(3):337\u0026ndash;49. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/j.1469-8986.2010.01075.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1469-8986.2010.01075.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMosaed S, Vahidi R, Lin KY. Effect of music tempo on operating room preparation time. Journal of perioperative practice 2020;30(5):141\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDalton B, Behm D. Effects of noise and music on human and task performance: A systematic review. Occupational Ergonomics 2007;7:143\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMikutta CA, Schwab S, Niederhauser S, et al. Music, perceived arousal, and intensity: Psychophysiological reactions to Chopin's \u0026ldquo;Tristesse\u0026rdquo;. Psychophysiology 2013;50(9):909\u0026ndash;19. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/psyp.12071\u003c/span\u003e\u003cspan address=\"10.1111/psyp.12071\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAllen AP, Kennedy PJ, Dockray S, et al. The Trier Social Stress Test: Principles and practice. Neurobiology of stress 2017;6:113\u0026ndash;26. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.ynstr.2016.11.001\u003c/span\u003e\u003cspan address=\"10.1016/j.ynstr.2016.11.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2017/02/24]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSussman RF, Sekuler R. Feeling rushed? Perceived time pressure impacts executive function and stress. Acta psychologica 2022;229:103702. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.actpsy.2022.103702\u003c/span\u003e\u003cspan address=\"10.1016/j.actpsy.2022.103702\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2022/08/20]\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFairclough S, Mulder B. Psychophysiological processes of mental effort investment2012:61\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatz JD. Noise in the operating room. Anesthesiology 2014;121(4):894\u0026ndash;8. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/aln.0000000000000319\u003c/span\u003e\u003cspan address=\"10.1097/aln.0000000000000319\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [published Online First: 2014/06/01]\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 1\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e. Heart rate variability parameters at baseline and during the simulated surgical task under music and control (non-music) conditions in the medical student (MS) and vascular surgeon (VS) groups.\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"933\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.613076098606644%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.971061093247588%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.971061093247588%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMusic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"18.971061093247588%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.473740621650588%\" colspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eANOVA P values\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.648764769065522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.311493018259936%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.70032223415682%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eVS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.915145005370569%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.841031149301826%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.774436090225564%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eInteraction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.648764769065522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRMSSD (ms)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e38.4\u0026plusmn;16.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e43.4\u0026plusmn;27.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.311493018259936%\" valign=\"bottom\"\u003e\n \u003cp\u003e36.3\u0026plusmn;12.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.70032223415682%\" valign=\"bottom\"\u003e\n \u003cp\u003e32.6\u0026plusmn;15.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e37.5\u0026plusmn;12.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e36.2\u0026plusmn;20.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.915145005370569%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.020\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.841031149301826%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.997\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.774436090225564%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.080\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.648764769065522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal power (ms\u003csup\u003e2\u003c/sup\u003e) \u003csup\u003e*\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e2144\u0026plusmn;1427\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e2521\u0026plusmn;2008\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.311493018259936%\" valign=\"bottom\"\u003e\n \u003cp\u003e2012\u0026plusmn;1107\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.70032223415682%\" valign=\"bottom\"\u003e\n \u003cp\u003e1356\u0026plusmn;853\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e2249\u0026plusmn;1340\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e1783\u0026plusmn;1313\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.915145005370569%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.045\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.841031149301826%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.596\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.774436090225564%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.069\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.648764769065522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh frequency (ms\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e788\u0026plusmn;708\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e752\u0026plusmn;1027\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.311493018259936%\" valign=\"bottom\"\u003e\n \u003cp\u003e549\u0026plusmn;394\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.70032223415682%\" valign=\"bottom\"\u003e\n \u003cp\u003e434\u0026plusmn;397\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e541\u0026plusmn;319\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e609\u0026plusmn;679\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.915145005370569%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.038\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.841031149301826%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.898\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.774436090225564%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.649\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.648764769065522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow frequency (ms\u003csup\u003e2\u003c/sup\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e1253\u0026plusmn;835\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e1598\u0026plusmn;1349\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.311493018259936%\" valign=\"bottom\"\u003e\n \u003cp\u003e1262\u0026plusmn;677\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.70032223415682%\" valign=\"bottom\"\u003e\n \u003cp\u003e845\u0026plusmn;508\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e1497\u0026plusmn;809\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e1062\u0026plusmn;589\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.915145005370569%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.841031149301826%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.501\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.774436090225564%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.055\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.648764769065522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eLF/HF ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.1\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.6\u0026plusmn;3.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.311493018259936%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.9\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.70032223415682%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.8\u0026plusmn;1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e2.9\u0026plusmn;1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e3.1\u0026plusmn;2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.915145005370569%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.834\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.841031149301826%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.400\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.774436090225564%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.296\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"16.648764769065522%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaevsky\u0026rsquo;s Index\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e11.1\u0026plusmn;5.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e9.2\u0026plusmn;2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.311493018259936%\" valign=\"bottom\"\u003e\n \u003cp\u003e10.8\u0026plusmn;2.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.70032223415682%\" valign=\"bottom\"\u003e\n \u003cp\u003e12.1\u0026plusmn;4.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e10.7\u0026plusmn;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.452201933404941%\" valign=\"bottom\"\u003e\n \u003cp\u003e11.4\u0026plusmn;4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"8.915145005370569%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.150\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.841031149301826%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.971\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.774436090225564%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.035\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eValues are mean with standard deviations for MS (n=15) and VS (n=12). P values show the results of two-way repeated measures analysis of variance. Results of post-hoc analysis with Tukey HSD shown as * = p\u0026lt;0.05 Music vs Control, RMSSD, root mean square of successive differences; LF/HF ratio, Low frequency/high frequency ratio.\u003cstrong\u003e\u003cbr\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cu\u003eTable 2\u003c/u\u003e\u003c/strong\u003e\u003cstrong\u003e. Psychological parameters at baseline and during the simulated surgical task under music and control (non-music) conditions in the medical student (MS) and vascular surgeon (VS) groups.\u003c/strong\u003e\u003c/p\u003e\n\u003cdiv align=\"\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"843\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.446555819477435%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"14.489311163895486%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.20190023752969%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMusic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.20190023752969%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eControl\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"32.6603325415677%\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eANOVA P values\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003eVS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCondition\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u003cstrong\u003eGroup\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u003cstrong\u003eInteraction\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eSTAI-6\u0026nbsp;\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal score \u003csup\u003e###\u0026nbsp;\u003c/sup\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003csup\u003e\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003csup\u003e\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e9\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e10\u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e12\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e12\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e13\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e12\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.854\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.376\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCalm \u003csup\u003e#### \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e3\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e3\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.837\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.268\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eRelaxed \u003csup\u003e## \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e3\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e3\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.864\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.135\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eContent \u003csup\u003e### \u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e3\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e3\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0003\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.489\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.789\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTense \u003csup\u003e## \u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e1\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e2\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.529\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.967\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eUpset \u003csup\u003e## \u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e1\u0026plusmn;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e1\u0026plusmn;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.922\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.807\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eWorried\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e1\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e1\u0026plusmn;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e1\u0026plusmn;0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.691\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.453\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.174\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cu\u003eSURG-TLX\u003c/u\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal score \u003csup\u003e#### \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e22\u0026plusmn;18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e30\u0026plusmn;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e62\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e47\u0026plusmn;23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e66\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e47\u0026plusmn;20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.155\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMental Demands \u003csup\u003e## \u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e4\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e8\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e12\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e9\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e12\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e9\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.017\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003ePhysical Demands \u003csup\u003e### \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e3\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e4\u0026plusmn;2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e9\u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e8\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e10\u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e7\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.014\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.044\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTemporal Demands \u003csup\u003e#### \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e3\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e5\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e11\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e10\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e11\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e9\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e0.966\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.414\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTask Complexity \u003csup\u003e#### \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e4\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e4\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e12\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e7\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e11\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e7\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eSituational Stress \u003csup\u003e### \u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e4\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e5\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e11\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e8\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e12\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e8\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.031\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e0.101\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"22.473246135552913%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistractedness \u003csup\u003e## \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.728894173602853%\"\u003e\n \u003cp\u003e3\u0026plusmn;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"6.777645659928656%\"\u003e\n \u003cp\u003e4\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e7\u0026plusmn;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e5\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e10\u0026plusmn;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"7.609988109393579%\"\u003e\n \u003cp\u003e8\u0026plusmn;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.17717003567182%\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.0001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"11.414982164090368%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"9.988109393579073%\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eValues are mean with standard deviations for MS (n=15) and VS (n=12). P values show the results of two-way repeated measures analysis of variance. Results of post-hoc analysis with Tukey HSD shown as * = p\u0026lt;0.05 Music vs Control. # = p\u0026lt;0.05, ## = p\u0026lt;0.01, ### p\u0026lt;0.001, #### = p\u0026lt;0.0001 Baseline vs. Music. \u0026dagger; = p\u0026lt;0.05, \u0026dagger;\u0026dagger; = p\u0026lt;0.01, \u0026dagger;\u0026dagger;\u0026dagger; p\u0026lt;0.001, \u0026dagger;\u0026dagger;\u0026dagger;\u0026dagger; = p\u0026lt;0.0001 Baseline vs Control. SURG-TLX, Surgical Taskload Index; STAI-6, Six-Item State-Trait Anxiety Inventory\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4225405/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4225405/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eHigh stress may diminish a surgeon\u0026rsquo;s performance in the operating room (OR). Music is perceived to reduce stress in the OR, however the psycho-physiological effects of music on intra-operative stress in inexperienced and experienced operators is incompletely understood. The effect of music on the psychological (Six-Item State-Trait Anxiety Inventory [STAI-6] and Surgical Taskload Index [SURG-TLX]) and physiological responses (e.g., heart rate variability) was determined to a simulated surgical task (carotid patch-angioplasty) in 15 medical students (MS) and 12 vascular surgeons (VS) under stressing conditions in a randomised crossover design. Music did not affect the speed or accuracy of the simulated surgical stress task performance. While the surgical task increased SURG-TLX scores from baseline to control (D32 [\u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39 CR40 CR41\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]; mean difference [95% confidence interval]) and to music (D30 [\u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24 CR25 CR26 CR27 CR28 CR29 CR30 CR31 CR32 CR33 CR34 CR35 CR36 CR37 CR38 CR39\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]), and increased STAI-6 scores in both conditions, there was no difference between music and control. The surgical task also increased heart rate (peak D5.1bpm [3.0-7.1] vs. baseline p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and cardiac sympathetic nervous system activity (SNS index), and reduced parasympathetic (PNS index) nervous system activity, with the latter two exacerbated by music (SNS: 0.14 [0.004\u0026ndash;0.27], p\u0026thinsp;=\u0026thinsp;0.042; PNS: -0.11 [-0.22 - -0.008], p\u0026thinsp;=\u0026thinsp;0.032). The more experienced group performed faster and more accurately than the inexperienced group, but there were no psychological or physiological differences in their responses to music. Despite previous research identifying generally positive surgeon perceptions of music on the intra-operative experience of stress, herein, background music failed to improve surgical task performance or attenuate subjective ratings of task load and anxiety, and physiological arousal.\u003c/p\u003e","manuscriptTitle":"Effect of background music on STress Responses Amongst Undergraduates and Surgeons performing Simulated Surgical tasks: A randomised cross-over interventional trial (The STRAUSS Study)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-09 18:08:29","doi":"10.21203/rs.3.rs-4225405/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-14T11:43:39+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"111785001192545393152143019891363387697","date":"2024-08-16T20:08:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-17T11:14:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"199113024739965096373708253740113533633","date":"2024-05-13T18:11:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"326310984291835112061816451522535321107","date":"2024-05-12T17:33:35+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-08T17:17:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-08T17:15:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-05-02T05:02:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-02T04:56:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2024-04-06T02:48:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5fd1a4da-a0c5-48cc-a68c-b5eb950f7d42","owner":[],"postedDate":"May 9th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":31637493,"name":"Biological sciences/Psychology/Human behaviour"},{"id":31637494,"name":"Biological sciences/Physiology/Circulation/Blood flow"},{"id":31637495,"name":"Health sciences/Diseases/Cardiovascular diseases/Vascular diseases/Carotid artery disease"},{"id":31637496,"name":"Health sciences/Health occupations"},{"id":31637497,"name":"Health sciences/Health care/Health services"}],"tags":[],"updatedAt":"2025-06-09T16:04:01+00:00","versionOfRecord":{"articleIdentity":"rs-4225405","link":"https://doi.org/10.1038/s41598-025-02202-9","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-06-03 15:57:46","publishedOnDateReadable":"June 3rd, 2025"},"versionCreatedAt":"2024-05-09 18:08:29","video":"","vorDoi":"10.1038/s41598-025-02202-9","vorDoiUrl":"https://doi.org/10.1038/s41598-025-02202-9","workflowStages":[]},"version":"v1","identity":"rs-4225405","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4225405","identity":"rs-4225405","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}