{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,5,29]],"date-time":"2025-05-29T19:28:29Z","timestamp":1748546909153,"version":"3.37.3"},"reference-count":29,"publisher":"Springer Science and Business Media LLC","issue":"7","license":[{"start":{"date-parts":[[2024,1,30]],"date-time":"2024-01-30T00:00:00Z","timestamp":1706572800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2024,1,30]],"date-time":"2024-01-30T00:00:00Z","timestamp":1706572800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100014584","name":"Universit\u00e4tsmedizin der Johannes Gutenberg-Universit\u00e4t Mainz","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100014584","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Strahlenther Onkol"],"published-print":{"date-parts":[[2024,7]]},"abstract":"<jats:title>Abstract<\/jats:title><jats:sec>\n                <jats:title>Purpose<\/jats:title>\n                <jats:p>Multiple myeloma is associated with osteolytic bone lesions, often requiring surgery of the spine and postoperative radiotherapy (RT). Although common, data for clinical and informed decision-making are sparse. In this monocentric retrospective study, we aim to report the outcome of patients who underwent spinal surgery and postoperative RT due to multiple myeloma.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Methods<\/jats:title>\n                <jats:p>A\u00a0total of 54\u00a0patients with multiple myeloma who underwent prior spinal surgery and postoperative RT at our institution between 2009 and 2020 were analyzed. Spinal instability neoplastic score (SINS) and Bilsky score, posttherapeutic adverse events, clinical data, and outcomes were collected and analyzed. The primary endpoint of this study was overall survival (OS), secondary endpoints were progression-free survival (PFS), pain response, local control, and skeletal-related events (SRE).<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Results<\/jats:title>\n                <jats:p>The 3\u2011 and 5\u2011year overall survival (OS) was 74.9% (95% confidence interval [CI]: 63.5\u201388.4%) and 58% (95% CI: 44.5\u201375.6%), respectively. Median survival was not reached and 75% survival was 34.3\u00a0months (95% CI: 28.7\u201395.4 months). Median follow-up was 63\u00a0months (95% CI: 49\u201394\u00a0months). The number of patients with good to adequate performance status (Karnofsky performance score [KPS] \u2265\u202f70) significantly increased after surgery (<jats:italic>p<\/jats:italic>\u202f&lt;\u20090.01). We observed no grade\u00a03\/4 toxicity and only 13 (24%) grade\u00a01\/2 adverse events. Two patients (4%) experienced SRE. Overall, 92% of patients reported reduced pain after radiotherapy, with 66% reporting complete pain response. There was no difference in pain response between patients with different Bilsky scores. Bisphosphonate therapy and lower Bilsky score at the start of RT were associated with improved OS in univariate analysis (all <jats:italic>p<\/jats:italic>\u202f&lt;\u20090.05). Multivariate Cox regression confirmed a\u00a0Bilsky score of\u00a02 or\u00a03 as an independent negative prognostic factor (HR 3.89; 95\u00a0CI 1.4\u201310.7; <jats:italic>p<\/jats:italic>\u202f&lt;\u20090.01). We observed no in-field recurrences.<\/jats:p>\n              <\/jats:sec><jats:sec>\n                <jats:title>Conclusion<\/jats:title>\n                <jats:p>In this study, we were able to show that the current standard of RT after spinal surgery of osteolytic lesions is safe. In addition, we observed a\u00a0very low rate of SRE (4%) and no in-field recurrences, demonstrating the local efficacy of RT in multiple myeloma patients. Higher Bilsky scores were associated with worse OS in multivariate analysis, but had no effect on pain response.<\/jats:p>\n              <\/jats:sec>","DOI":"10.1007\/s00066-024-02198-7","type":"journal-article","created":{"date-parts":[[2024,1,30]],"date-time":"2024-01-30T15:03:26Z","timestamp":1706627006000},"page":"633-641","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Excellent long-term pain response and local control following postoperative radiotherapy in patients with multiple myeloma"],"prefix":"10.1007","volume":"200","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0189-3499","authenticated-orcid":false,"given":"Justus","family":"Kaufmann","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Annika Ute","family":"T\u00e4ubl","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Eirini","family":"Nikolaidou","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alexander","family":"R\u00fchle","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anne","family":"Hopprich","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel","family":"Wollschl\u00e4ger","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Arnulf","family":"Mayer","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Nils Henrik","family":"Nicolay","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Heinz","family":"Schmidberger","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Tilman","family":"Bostel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2024,1,30]]},"reference":[{"key":"2198_CR1","doi-asserted-by":"publisher","first-page":"2645","DOI":"10.1056\/NEJMct0805626","volume":"360","author":"J-L Harousseau","year":"2009","unstructured":"Harousseau\u00a0J\u2011L, Moreau\u00a0P (2009) Autologous Hematopoietic Stem-Cell Transplantation for Multiple Myeloma. N\u00a0Engl J Med 360:2645\u20132654. https:\/\/doi.org\/10.1056\/NEJMct0805626","journal-title":"N Engl J Med"},{"key":"2198_CR2","doi-asserted-by":"publisher","first-page":"33","DOI":"10.4137\/CGM.S16817","volume":"7","author":"A Hameed","year":"2014","unstructured":"Hameed\u00a0A, Brady\u00a0JJ, Dowling\u00a0P et\u00a0al (2014) Bone Disease in Multiple Myeloma: Pathophysiology and Management. Cancer Growth Metastasis 7:33\u201342. https:\/\/doi.org\/10.4137\/CGM.S16817","journal-title":"Cancer Growth Metastasis"},{"key":"2198_CR3","doi-asserted-by":"publisher","first-page":"1121","DOI":"10.1200\/JCO.2006.08.5803","volume":"25","author":"R Walker","year":"2007","unstructured":"Walker\u00a0R, Barlogie\u00a0B, Haessler\u00a0J et\u00a0al (2007) Magnetic Resonance Imaging in Multiple Myeloma: Diagnostic and Clinical Implications. J\u00a0Clin Oncol 25:1121\u20131128. https:\/\/doi.org\/10.1200\/JCO.2006.08.5803","journal-title":"J Clin Oncol"},{"key":"2198_CR4","doi-asserted-by":"publisher","unstructured":"Adamietz IA, Schober C, Schulte RWM, et\u00a0al (1991) Palliative radiotherapy in plasma cell myeloma. Radiother Oncol 20:111\u2013116. https:\/\/doi.org\/10.1016\/0167-8140(91)90144\u20116","DOI":"10.1016\/0167-8140"},{"key":"2198_CR5","doi-asserted-by":"publisher","first-page":"103205","DOI":"10.1016\/j.critrevonc.2020.103205","volume":"160","author":"B Chen","year":"2021","unstructured":"Chen\u00a0B, Cai\u00a0L, Zhou\u00a0F (2021) Management of acute spinal cord compression in multiple myeloma. Crit Rev Oncol Hematol 160:103205. https:\/\/doi.org\/10.1016\/j.critrevonc.2020.103205","journal-title":"Crit Rev Oncol Hematol"},{"key":"2198_CR6","doi-asserted-by":"publisher","first-page":"104546","DOI":"10.1155\/2013\/104546","volume":"2013","author":"P Tosi","year":"2013","unstructured":"Tosi\u00a0P (2013) Diagnosis and Treatment of Bone Disease in Multiple Myeloma: Spotlight on Spinal Involvement. Scientifica 2013:104546. https:\/\/doi.org\/10.1155\/2013\/104546","journal-title":"Scientifica"},{"key":"2198_CR7","first-page":"29","volume":"50","author":"RA Kyle","year":"1975","unstructured":"Kyle\u00a0RA (1975) Multiple myeloma: review of 869 cases. Mayo Clin Proc 50:29\u201340","journal-title":"Mayo Clin Proc"},{"key":"2198_CR8","doi-asserted-by":"publisher","first-page":"743","DOI":"10.1046\/j.1365-2141.1997.d01-2108.x","volume":"96","author":"F Lecouvet","year":"1997","unstructured":"Lecouvet\u00a0F, Richard\u00a0F, Berg\u00a0BV et\u00a0al (1997) Long-term effects of localized spinal radiation therapy on vertebral fractures and focal lesions appearance in patients with multiple myeloma. Br J Haematol 96:743\u2013745. https:\/\/doi.org\/10.1046\/j.1365-2141.1997.d01-2108.x","journal-title":"Br J Haematol"},{"key":"2198_CR9","doi-asserted-by":"publisher","first-page":"e99","DOI":"10.1016\/j.clml.2017.09.005","volume":"17","author":"K Lang","year":"2017","unstructured":"Lang\u00a0K, K\u00f6nig\u00a0L, Bruckner\u00a0T et\u00a0al (2017) Stability of Spinal Bone Lesions in Patients With Multiple Myeloma After Radiotherapy\u2014A Retrospective Analysis of 130 Cases. Clin Lymphoma Myeloma Leuk 17:e99\u2013e107. https:\/\/doi.org\/10.1016\/j.clml.2017.09.005","journal-title":"Clin Lymphoma Myeloma Leuk"},{"key":"2198_CR10","series-title":"Al","doi-asserted-by":"publisher","first-page":"114","DOI":"10.1007\/s00066-010-2155-9","volume-title":"Impact of radiotherapy on pain relief and recalcification in plasma cell neoplasms: long-term experience. Strahlenther Onkol Organ Dtsch Rontgengesellschaft","author":"M Balducci","year":"2011","unstructured":"Balducci\u00a0M, Chiesa\u00a0S, Manfrida\u00a0S et\u00a0al (2011) Impact of radiotherapy on pain relief and recalcification in plasma cell neoplasms: long-term experience. Strahlenther Onkol Organ Dtsch Rontgengesellschaft. Al, vol 187, pp\u00a0114\u2013119 https:\/\/doi.org\/10.1007\/s00066-010-2155-9"},{"key":"2198_CR11","doi-asserted-by":"publisher","first-page":"506","DOI":"10.1007\/PL00002317","volume":"176","author":"S Mose","year":"2000","unstructured":"Mose\u00a0S, Pfitzner\u00a0D, Rahn\u00a0A et\u00a0al (2000) Wertigkeit der Radiotherapie in der Behandlung des multiplen Myeloms. Strahlenther Onkol 176:506\u2013512. https:\/\/doi.org\/10.1007\/PL00002317","journal-title":"Strahlenther Onkol"},{"key":"2198_CR12","doi-asserted-by":"publisher","first-page":"794","DOI":"10.1016\/j.ijrobp.2018.05.009","volume":"101","author":"RW Tsang","year":"2018","unstructured":"Tsang\u00a0RW, Campbell\u00a0BA, Goda\u00a0JS et\u00a0al (2018) Radiation therapy for solitary plasmacytoma and multiple myeloma: guidelines from the international lymphoma radiation oncology group. Int J Radiat Oncol Biol Phys 101:794\u2013808. https:\/\/doi.org\/10.1016\/j.ijrobp.2018.05.009","journal-title":"Int J Radiat Oncol Biol Phys"},{"key":"2198_CR13","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1186\/s13014-020-01737-7","volume":"16","author":"D Rades","year":"2021","unstructured":"Rades\u00a0D, Cacicedo\u00a0J, Conde-Moreno\u00a0AJ et\u00a0al (2021) Comparison of 5\u00a0\u00d7 5\u202fGy and 10\u00a0\u00d7 3\u202fGy for metastatic spinal cord compression using data from three prospective trials. Radiat Oncol 16:7. https:\/\/doi.org\/10.1186\/s13014-020-01737-7","journal-title":"Radiat Oncol"},{"key":"2198_CR14","doi-asserted-by":"publisher","first-page":"1452","DOI":"10.1016\/j.ijrobp.2005.10.018","volume":"64","author":"D Rades","year":"2006","unstructured":"Rades\u00a0D, Hoskin\u00a0PJ, Stalpers\u00a0LJA et\u00a0al (2006) Short-course radiotherapy is not optimal for spinal cord compression due to myeloma. Int J Radiat Oncol Biol Phys 64:1452\u20131457. https:\/\/doi.org\/10.1016\/j.ijrobp.2005.10.018","journal-title":"Int J Radiat Oncol Biol Phys"},{"key":"2198_CR15","doi-asserted-by":"publisher","first-page":"597","DOI":"10.1200\/JCO.2015.64.0862","volume":"34","author":"D Rades","year":"2016","unstructured":"Rades\u00a0D, \u0160egedin\u00a0B, Conde-Moreno\u00a0AJ et\u00a0al (2016) Radiotherapy With 4\u202fGy\u00a0\u00d7 5 Versus 3\u202fGy\u00a0\u00d7 10 for Metastatic Epidural Spinal Cord Compression: Final Results of the SCORE\u20112 Trial (ARO 2009\/01). J\u00a0Clin Oncol 34:597\u2013602. https:\/\/doi.org\/10.1200\/JCO.2015.64.0862","journal-title":"J Clin Oncol"},{"key":"2198_CR16","doi-asserted-by":"publisher","first-page":"742","DOI":"10.1007\/s00066-017-1154-5","volume":"193","author":"M Rudzianskiene","year":"2017","unstructured":"Rudzianskiene\u00a0M, Inciura\u00a0A, Gerbutavicius\u00a0R et\u00a0al (2017) Single vs. multiple fraction regimens for palliative radiotherapy treatment of multiple myeloma. Strahlenther Onkol 193:742\u2013749. https:\/\/doi.org\/10.1007\/s00066-017-1154-5","journal-title":"Strahlenther Onkol"},{"key":"2198_CR17","doi-asserted-by":"publisher","first-page":"e355","DOI":"10.3324\/haematol.2019.235804","volume":"105","author":"A Elhammali","year":"2020","unstructured":"Elhammali\u00a0A, Amini\u00a0B, Ludmir\u00a0EB et\u00a0al (2020) New paradigm for radiation in multiple myeloma: lower yet effective dose to avoid radiation toxicity. Haematologica 105:e355\u2013e357. https:\/\/doi.org\/10.3324\/haematol.2019.235804","journal-title":"Haematologica"},{"key":"2198_CR18","doi-asserted-by":"publisher","first-page":"67","DOI":"10.1089\/jpm.2022.0173","volume":"26","author":"JC Farris","year":"2023","unstructured":"Farris\u00a0JC, Johnson\u00a0AG, Carriere\u00a0PP et\u00a0al (2023) Palliative Appropriateness Criteria: A\u00a0Pragmatic Method to Evaluate the Suitability of Palliative Radiotherapy Fractionation. J\u00a0Palliat Med 26:67\u201372. https:\/\/doi.org\/10.1089\/jpm.2022.0173","journal-title":"J Palliat Med"},{"key":"2198_CR19","doi-asserted-by":"publisher","first-page":"149","DOI":"10.1111\/ajco.13783","volume":"19","author":"WL Ong","year":"2023","unstructured":"Ong\u00a0WL, MacManus\u00a0M, Milne\u00a0RL et\u00a0al (2023) Large variation in radiation therapy fractionation for multiple myeloma in Australia. Asia Pac J Clin Oncol 19:149\u2013157. https:\/\/doi.org\/10.1111\/ajco.13783","journal-title":"Asia Pac J Clin Oncol"},{"key":"2198_CR20","doi-asserted-by":"publisher","first-page":"91","DOI":"10.1056\/NEJM199607113350204","volume":"335","author":"M Attal","year":"1996","unstructured":"Attal\u00a0M, Harousseau\u00a0J\u2011L, Stoppa\u00a0A\u2011M et\u00a0al (1996) A Prospective, Randomized Trial of Autologous Bone Marrow Transplantation and Chemotherapy in Multiple Myeloma. N\u00a0Engl J Med 335:91\u201397. https:\/\/doi.org\/10.1056\/NEJM199607113350204","journal-title":"N Engl J Med"},{"key":"2198_CR21","doi-asserted-by":"publisher","first-page":"1122","DOI":"10.1038\/leu.2013.313","volume":"28","author":"SK Kumar","year":"2014","unstructured":"Kumar\u00a0SK, Dispenzieri\u00a0A, Lacy\u00a0MQ et\u00a0al (2014) Continued improvement in survival in multiple myeloma: changes in early mortality and outcomes in older patients. Leukemia 28:1122\u20131128. https:\/\/doi.org\/10.1038\/leu.2013.313","journal-title":"Leukemia"},{"key":"2198_CR22","series-title":"Spine","doi-asserted-by":"publisher","first-page":"E1221","DOI":"10.1097\/BRS.0b013e3181e16ae2","volume-title":"A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and","author":"CG Fisher","year":"2010","unstructured":"Fisher\u00a0CG, DiPaola\u00a0CP, Ryken\u00a0TC et\u00a0al (2010) A novel classification system for spinal instability in neoplastic disease: an evidence-based approach and. Spine, vol 35. expert, consensus from the Spine Oncology Study Group, pp E1221\u20131229 https:\/\/doi.org\/10.1097\/BRS.0b013e3181e16ae2"},{"key":"2198_CR23","doi-asserted-by":"publisher","unstructured":"Bilsky MH, Laufer I, Fourney DR, et\u00a0al (2010) Reliability analysis of the epidural spinal cord compression scale: Clinical article. J\u00a0Neurosurg Spine 13:324\u2013328. https:\/\/doi.org\/10.3171\/2010.3.SPINE09459","DOI":"10.3171\/2010.3.SPINE09459"},{"key":"2198_CR24","doi-asserted-by":"publisher","first-page":"1319","DOI":"10.1227\/neu.0000000000002586","volume":"93","author":"GA Bendfeldt","year":"2023","unstructured":"Bendfeldt\u00a0GA, Chanbour\u00a0H, Chen\u00a0JW et\u00a0al (2023) Does Low-Grade Versus High-Grade Bilsky Score Influence Local Recurrence and Overall Survival in Metastatic Spine Tumor Surgery? Neurosurgery 93:1319\u20131330. https:\/\/doi.org\/10.1227\/neu.0000000000002586","journal-title":"Neurosurgery"},{"key":"2198_CR25","unstructured":"Costas I, Claybour P, Borah AJ et\u00a0al (2003) The Measurement of comorbidity in cancer regisitries. J\u00a0Regist Manag 30:"},{"key":"2198_CR26","doi-asserted-by":"publisher","first-page":"2441","DOI":"10.1001\/jama.291.20.2441","volume":"291","author":"JF Piccirillo","year":"2004","unstructured":"Piccirillo\u00a0JF, Tierney\u00a0RM, Costas\u00a0I et\u00a0al (2004) Prognostic Importance of Comorbidity in a\u00a0Hospital-Based Cancer Registry. JAMA 291:2441\u20132447. https:\/\/doi.org\/10.1001\/jama.291.20.2441","journal-title":"JAMA"},{"key":"2198_CR27","volume-title":"R: A\u00a0Language and Environment for Statistical Computing","author":"R Core Team","year":"2022","unstructured":"R Core Team (2022) R: A\u00a0Language and Environment for Statistical Computing. R Foundation for Statistical Computing, Vienna, Austria"},{"key":"2198_CR28","doi-asserted-by":"publisher","first-page":"2909","DOI":"10.3390\/cancers15112909","volume":"15","author":"M Oertel","year":"2023","unstructured":"Oertel\u00a0M, Schlusemann\u00a0T, Shumilov\u00a0E et\u00a0al (2023) Radiotherapy in Combination with Systemic Therapy for Multiple Myeloma\u2014A Critical Toxicity Evaluation in the Modern Treatment Era. Cancers 15:2909. https:\/\/doi.org\/10.3390\/cancers15112909","journal-title":"Cancers"},{"key":"2198_CR29","doi-asserted-by":"publisher","first-page":"71","DOI":"10.1186\/s13014-015-0374-z","volume":"10","author":"C Matuschek","year":"2015","unstructured":"Matuschek\u00a0C, Ochtrop\u00a0TA, B\u00f6lke\u00a0E et\u00a0al (2015) Effects of Radiotherapy in the treatment of multiple myeloma: a\u00a0retrospective analysis of a\u00a0Single Institution. Radiat Oncol 10:71. https:\/\/doi.org\/10.1186\/s13014-015-0374-z","journal-title":"Radiat Oncol"}],"container-title":["Strahlentherapie und Onkologie"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00066-024-02198-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s00066-024-02198-7\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s00066-024-02198-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,6,19]],"date-time":"2024-06-19T16:03:56Z","timestamp":1718813036000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/10.1007\/s00066-024-02198-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,1,30]]},"references-count":29,"journal-issue":{"issue":"7","published-print":{"date-parts":[[2024,7]]}},"alternative-id":["2198"],"URL":"https:\/\/doi.org\/10.1007\/s00066-024-02198-7","relation":{},"ISSN":["0179-7158","1439-099X"],"issn-type":[{"type":"print","value":"0179-7158"},{"type":"electronic","value":"1439-099X"}],"subject":[],"published":{"date-parts":[[2024,1,30]]},"assertion":[{"value":"18 July 2023","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"3 January 2024","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"30 January 2024","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"J.\u00a0Kaufmann, A.U.\u00a0T\u00e4ubl, E.\u00a0Nikolaidou, A.\u00a0R\u00fchle, A.\u00a0Hopprich, D.\u00a0Wollschl\u00e4ger, A.\u00a0Mayer, N.H.\u00a0Nicolay, H.\u00a0Schmidberger, and T.\u00a0Bostel declare that they have no competing interests.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"All human studies have been approved by the appropriate ethics committee and have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical standards"}}]}}