{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,4,7]],"date-time":"2025-04-07T05:44:47Z","timestamp":1744004687057,"version":"3.37.3"},"reference-count":40,"publisher":"Springer Science and Business Media LLC","issue":"3","license":[{"start":{"date-parts":[[2019,11,4]],"date-time":"2019-11-04T00:00:00Z","timestamp":1572825600000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2019,11,4]],"date-time":"2019-11-04T00:00:00Z","timestamp":1572825600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"DOI":"10.13039\/501100009232","name":"University of Debrecen","doi-asserted-by":"crossref","id":[{"id":"10.13039\/501100009232","id-type":"DOI","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Folia Microbiol"],"published-print":{"date-parts":[[2020,6]]},"abstract":"<jats:title>Abstract<\/jats:title>\n<jats:p>Excessive use of antibiotics contributes to the selection of resistant bacteria and intestinal colonization with multiresistant pathogens poses a risk factor for subsequent infections. The present study assessed vancomycin-resistant enterococci (VRE) carriage rates in patients admitted to our tertiary care hospital. Stool samples sent for routine culturing were screened with vancomycin containing solid or broth enrichment media. VRE isolates were identified with matrix-assisted laser desorption\/ionization-time of flight mass spectrometry and antibiotic susceptibilities were tested by E-test. Vancomycin resistance genes were detected by polymerase chain reaction. Medical records of carriers were examined for suspected risk factors for colonization. Altogether 3025 stool specimens were analyzed. Solid media identified a VRE carriage rate of 2.2% while broth enrichment detected 5.8%. Seventy percent of the isolates were <jats:italic>Enterococcus faecium. VanB<\/jats:italic> genotype was detected in 38.2%, <jats:italic>VanA<\/jats:italic> in 37.3%, <jats:italic>VanC1<\/jats:italic> in 22.6%, and <jats:italic>VanC2<\/jats:italic> in 1.9%. All VRE were sensitive to linezolid, daptomycin, and tigecycline. Collective risk factors for carriage were diabetes, normal flora absence, <jats:italic>Clostridioides difficile<\/jats:italic> positivity, longer hospital stay, and advanced age. 78.5% of the carriers received antibiotic therapy which was metronidazole in most cases (47.3%)<jats:italic>.<\/jats:italic> We recommend regular screening of risk groups such as patients with diabetes, history of recent hospitalization, or former <jats:italic>C. difficile<\/jats:italic> infection as an imperative step for preventing VRE dissemination.<\/jats:p>","DOI":"10.1007\/s12223-019-00751-x","type":"journal-article","created":{"date-parts":[[2019,11,4]],"date-time":"2019-11-04T10:02:57Z","timestamp":1572861777000},"page":"483-490","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":4,"title":["Assessing the intestinal carriage rates of vancomycin-resistant enterococci (VRE) at a tertiary care hospital in Hungary"],"prefix":"10.1007","volume":"65","author":[{"given":"Dorottya","family":"Frany\u00f3","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Bal\u00e1zs","family":"Kocsi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Evelin Erzs\u00e9bet","family":"Bukta","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Judit","family":"Szab\u00f3","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4689-2924","authenticated-orcid":false,"given":"Zsuzsanna","family":"Dombr\u00e1di","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"297","published-online":{"date-parts":[[2019,11,4]]},"reference":[{"issue":"1","key":"751_CR1","doi-asserted-by":"crossref","first-page":"ofw246","DOI":"10.1093\/ofid\/ofw246","volume":"4","author":"M Alevizakos","year":"2016","unstructured":"Alevizakos M, Gaitanidis A, Nasioudis D et al (2016) Colonization with vancomycin-resistant enterococci and risk for bloodstream infection among patients with malignancy: a systematic review and meta-analysis. Open Forum Infect Dis 4(1):ofw246","journal-title":"Open Forum Infect Dis"},{"issue":"9","key":"751_CR2","first-page":"06","volume":"10","author":"R Amberpet","year":"2016","unstructured":"Amberpet R, Sistla S, Parija SC et al (2016) Screening for intestinal colonization with vancomycin resistant enterococci and associated risk factors among patients admitted to an adult intensive care unit of a large teaching hospital. J Clin Diagn Res 10(9):06\u201309","journal-title":"J Clin Diagn Res"},{"issue":"1","key":"751_CR3","first-page":"E050127.1","volume":"10","author":"K B\u00f6r\u00f6cz","year":"2005","unstructured":"B\u00f6r\u00f6cz K, Szil\u00e1gyi E, Kurcz A et al (2005) First vancomycin-resistant Enterococcus faecium outbreak reported in Hungary. Euro Surveill 10(1):E050127.1","journal-title":"Euro Surveill"},{"issue":"1","key":"751_CR4","doi-asserted-by":"crossref","first-page":"104","DOI":"10.1016\/j.clinbiochem.2010.06.017","volume":"44","author":"E Carbonnelle","year":"2011","unstructured":"Carbonnelle E, Mesquita C, Bille E et al (2011) MALDI-TOF mass spectrometry tools for bacterial identification in clinical microbiology laboratory. Clin Biochem 44(1):104\u2013109","journal-title":"Clin Biochem"},{"issue":"4","key":"751_CR5","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1128\/CMR.13.4.686","volume":"13","author":"Y Cetinkaya","year":"2000","unstructured":"Cetinkaya Y, Falk P, Mayhall CG (2000) Vancomycin-resistant enterococci. Clin Microbiol Rev 13(4):686\u2013707","journal-title":"Clin Microbiol Rev"},{"key":"751_CR6","doi-asserted-by":"crossref","first-page":"514","DOI":"10.1186\/1471-2334-14-514","volume":"14","author":"VCC Cheng","year":"2014","unstructured":"Cheng VCC, Chen JHK, Tai JWM et al (2014) Decolonization of gastrointestinal carriage of vancomycin-resistant Enterococcus faecium: case series and review of literature. BMC Infect Dis 14:514","journal-title":"BMC Infect Dis"},{"issue":"5","key":"751_CR7","doi-asserted-by":"crossref","first-page":"316","DOI":"10.1067\/mic.2001.117448","volume":"29","author":"EMC D\u2019Agata","year":"2001","unstructured":"D\u2019Agata EMC, Jirjis J, Gouldin C et al (2001) Community dissemination of vancomycin-resistant Enterococcus faecium. Am J Infect Control 29(5):316\u2013320","journal-title":"Am J Infect Control"},{"issue":"12","key":"751_CR8","doi-asserted-by":"crossref","first-page":"5857","DOI":"10.1128\/JCM.42.12.5857-5860.2004","volume":"42","author":"F Depardieu","year":"2004","unstructured":"Depardieu F, Perichon B, Courvalin P (2004) Detection of the van alphabet and identification of enterococci and staphylococci at the species level by multiplex PCR. J Clin Microbiol 42(12):5857\u20135860","journal-title":"J Clin Microbiol"},{"issue":"7","key":"751_CR9","doi-asserted-by":"crossref","first-page":"2307","DOI":"10.1128\/AAC.47.7.2307-2309.2003","volume":"47","author":"J Dina","year":"2003","unstructured":"Dina J, Malbruny B, Leclercq R et al (2003) Nonsense mutations in the lsa-like gene in Enterococcus faecalis isolates susceptible to lincosamides and streptogramins A. Antimicrob Agents Chemother 47(7):2307\u20132309","journal-title":"Antimicrob Agents Chemother"},{"issue":"1","key":"751_CR10","doi-asserted-by":"crossref","first-page":"47","DOI":"10.1089\/mdr.2011.0014","volume":"18","author":"Z Dombr\u00e1di","year":"2012","unstructured":"Dombr\u00e1di Z, Dobay O, Nagy K et al (2012) Prevalence of vanC vancomycin-resistant enterococci in the teaching hospitals of the University of Debrecen, Hungary. Microb Drug Resist 18(1):47\u201351","journal-title":"Microb Drug Resist"},{"issue":"26","key":"751_CR11","doi-asserted-by":"crossref","first-page":"1925","DOI":"10.1056\/NEJM200012283432604","volume":"343","author":"CJ Donskey","year":"2000","unstructured":"Donskey CJ, Chowdhry TK, Hecker MT et al (2000) Effect of antibiotic therapy on the density of vancomycin-resistant enterococci in the stool of colonized patients. N Engl J Med 343(26):1925\u20131932","journal-title":"N Engl J Med"},{"key":"751_CR12","volume-title":"Annual epidemiological report 2016: healthcare-associated infections acquired in intensive care units","author":"European Centre for Disease Prevention and Control","year":"2016","unstructured":"European Centre for Disease Prevention and Control (2016) Annual epidemiological report 2016: healthcare-associated infections acquired in intensive care units. ECDC, Stockholm"},{"key":"751_CR13","volume-title":"Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net)","author":"European Centre for Disease Prevention and Control","year":"2017","unstructured":"European Centre for Disease Prevention and Control (2017) Surveillance of antimicrobial resistance in Europe 2016. In: Annual Report of the European Antimicrobial Resistance Surveillance Network (EARS-Net). ECDC, Stockholm"},{"key":"751_CR14","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1089\/mdr.2018.0074","volume":"24","author":"D Frany\u00f3","year":"2018","unstructured":"Frany\u00f3 D, Kocsi B, Lesinszki V et al (2018) Characterization of clinical vancomycin-resistant Enterococcus faecium isolated in Eastern Hungary. Microb Drug Resist 24:10","journal-title":"Microb Drug Resist"},{"issue":"2","key":"751_CR15","doi-asserted-by":"crossref","first-page":"620","DOI":"10.1128\/JCM.38.2.620-624.2000","volume":"38","author":"K Gambarotto","year":"2000","unstructured":"Gambarotto K, Ploy MC, Turlure P et al (2000) Prevalence of vancomycin-resistant enterococci in fecal samples from hospitalized patients and nonhospitalized controls in a cattle-rearing area of France. J Clin Microbiol 38(2):620\u2013624","journal-title":"J Clin Microbiol"},{"issue":"14","key":"751_CR16","doi-asserted-by":"crossref","first-page":"4234","DOI":"10.1128\/AEM.00740-14","volume":"80","author":"MT Gekenidis","year":"2014","unstructured":"Gekenidis MT, Studer P, W\u00fcthrich S et al (2014) Beyond the matrix-assisted laser desorption ionization (MALDI) biotyping workflow: in search of microorganism-specific tryptic peptides enabling discrimination of subspecies. Appl Environ Microbiol 80(14):4234\u20134241","journal-title":"Appl Environ Microbiol"},{"key":"751_CR17","doi-asserted-by":"crossref","first-page":"325","DOI":"10.1093\/jac\/46.2.325","volume":"46","author":"\u00c1 Ghid\u00e1n","year":"2000","unstructured":"Ghid\u00e1n \u00c1, Csisz\u00e1r K, Cs J et al (2000) PCR detection of the vanA gene in a vancomycin-resistant Enterococcus faecalis. J Antimicrob Chemother 46:325\u2013326","journal-title":"J Antimicrob Chemother"},{"issue":"4","key":"751_CR18","doi-asserted-by":"crossref","first-page":"409","DOI":"10.1556\/AMicr.55.2008.4.5","volume":"55","author":"A Ghid\u00e1n","year":"2008","unstructured":"Ghid\u00e1n A, Dobay O, Kaszanyitzky EJ et al (2008) Vancomycin resistant enterococci (VRE) still persist in slaughtered poultry in Hungary 8 years after the ban on avoparcin. Acta Microbiol Immunol Hung 55(4):409\u2013417","journal-title":"Acta Microbiol Immunol Hung"},{"issue":"4","key":"751_CR19","doi-asserted-by":"crossref","first-page":"412","DOI":"10.1128\/mBio.00412-13","volume":"4","author":"BP Howden","year":"2013","unstructured":"Howden BP, Holt KH, Lam MMC et al (2013) Genomic insights to control the emergence of vancomycin-resistant enterococci. mBio 4(4):412\u2013413","journal-title":"mBio"},{"issue":"2","key":"751_CR20","doi-asserted-by":"crossref","first-page":"239","DOI":"10.3201\/eid0402.980211","volume":"4","author":"MM Huycke","year":"1998","unstructured":"Huycke MM, Sahm DF, Gilmore MS (1998) Multiple-drug resistant enterococci: the nature of the problem and an agenda for the future. Emerg Infect Dis 4(2):239\u2013249","journal-title":"Emerg Infect Dis"},{"issue":"5","key":"751_CR21","doi-asserted-by":"crossref","first-page":"1436","DOI":"10.1128\/JCM.37.5.1436-1440.1999","volume":"37","author":"M Ieven","year":"1999","unstructured":"Ieven M, Vercauteren E, Descheemaeker P et al (1999) Comparison of direct plating and broth enrichment culture for the detection of intestinal colonization by glycopeptide-resistant enterococci among hospitalized patients. J Clin Microbiol 37(5):1436\u20131440","journal-title":"J Clin Microbiol"},{"issue":"4","key":"751_CR22","doi-asserted-by":"crossref","first-page":"462","DOI":"10.1128\/CMR.7.4.462","volume":"7","author":"BD Jett","year":"1994","unstructured":"Jett BD, Huycke MM, Gilmore MS (1994) Virulence of enterococci. Clin Microbiol Rev 7(4):462\u2013478","journal-title":"Clin Microbiol Rev"},{"key":"751_CR23","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1186\/2047-2994-1-31","volume":"1","author":"S Karki","year":"2012","unstructured":"Karki S, Houston L, Land G et al (2012) Prevalence and risk factors for VRE colonisation in a tertiary hospital in Melbourne, Australia: a cross sectional study. Antimicrob Resist Infect Control 1:31","journal-title":"Antimicrob Resist Infect Control"},{"issue":"1","key":"751_CR24","doi-asserted-by":"crossref","first-page":"119","DOI":"10.1016\/j.ijfoodmicro.2006.10.004","volume":"115","author":"EJ Kaszanyitzky","year":"2007","unstructured":"Kaszanyitzky EJ, Tenk M, Ghid\u00e1n A et al (2007) Antimicrobial susceptibility of enterococci strains isolated from slaughter animals on the data of Hungarian resistance monitoring system from 2001 to 2004. Int J Food Microbiol 115(1):119\u2013123","journal-title":"Int J Food Microbiol"},{"issue":"3","key":"751_CR25","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1056\/NEJM198807213190307","volume":"319","author":"R Leclercq","year":"1988","unstructured":"Leclercq R, Derlot E, Duval J et al (1988) Plasmid-mediated resistance to vancomycin and teicoplanin in Enterococcus faecium. N Engl J Med 319(3):157\u2013161","journal-title":"N Engl J Med"},{"issue":"10","key":"751_CR26","doi-asserted-by":"crossref","first-page":"778","DOI":"10.1080\/00365540802165740","volume":"40","author":"B Libisch","year":"2008","unstructured":"Libisch B, Lepsanovic Z, Top J et al (2008) Molecular characterization of vancomycin-resistant Enterococcus spp. clinical isolates from Hungary and Serbia. Scand J Infect Dis 40(10):778\u2013784","journal-title":"Scand J Infect Dis"},{"issue":"5","key":"751_CR27","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1086\/502213","volume":"24","author":"CA Muto","year":"2003","unstructured":"Muto CA, Jernigan JA, Ostrowsky BE et al (2003) SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol 24(5):362\u2013386","journal-title":"Infect Control Hosp Epidemiol"},{"key":"751_CR28","volume-title":"Enterococci: From Commensals to Leading Causes of Drug Resistant Infection","author":"I Nelson","year":"2014","unstructured":"Nelson I, Higuita A, Huycke MM (2014) Enterococcal disease, epidemiology, and implications for treatment. In: Gilmore MS, Clewell DB, Ike Y, Shankar N (eds) Enterococci: From Commensals to Leading Causes of Drug Resistant Infection. Massachusetts Eye and Ear Infirmary, Boston"},{"key":"751_CR29","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1111\/j.1574-6968.1992.tb05089.x","volume":"72","author":"WC Noble","year":"1992","unstructured":"Noble WC, Virani Z, Cree RG (1992) Co-transfer of vancomycin and other resistance genes from Enterococcus faecalis NCTC 12201 to Staphylococcus aureus. FEMS Microbiol Lett 72:195\u2013198","journal-title":"FEMS Microbiol Lett"},{"issue":"4","key":"751_CR30","doi-asserted-by":"crossref","first-page":"1637","DOI":"10.1128\/JCM.42.4.1637-1640.2004","volume":"42","author":"TJ Novicki","year":"2004","unstructured":"Novicki TJ, Schapiro JM, Ulness BK et al (2004) Convenient selective differential broth for isolation of vancomycin-resistant enterococcus from fecal material. J Clin Microbiol 42(4):1637\u20131640","journal-title":"J Clin Microbiol"},{"issue":"3","key":"751_CR31","doi-asserted-by":"crossref","first-page":"489","DOI":"10.1016\/j.bjm.2016.12.012","volume":"48","author":"S \u00d6zsoy","year":"2017","unstructured":"\u00d6zsoy S, \u0130lki A (2017) Detection of vancomycin-resistant enterococci (VRE) in stool specimens submitted for Clostridium difficile toxin testing. Braz J Microbiol 48(3):489\u2013492","journal-title":"Braz J Microbiol"},{"issue":"9","key":"751_CR32","first-page":"DC01","volume":"11","author":"G Purohit","year":"2017","unstructured":"Purohit G, Gaind R, Dawar R et al (2017) Characterization of vancomycin resistant enterococci in hospitalized patients and role of gut colonization. J Clin Diagn Res 11(9):DC01\u2013DC05","journal-title":"J Clin Diagn Res"},{"issue":"4","key":"751_CR33","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1086\/600885","volume":"49","author":"P Seng","year":"2009","unstructured":"Seng P, Drancourt M, Gouriet F et al (2009) Ongoing revolution in bacteriology: routine identification of bacteria by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Clin Infect Dis 49(4):543\u2013551","journal-title":"Clin Infect Dis"},{"issue":"4","key":"751_CR34","doi-asserted-by":"crossref","first-page":"e240","DOI":"10.1016\/j.ijid.2012.09.019","volume":"17","author":"KM Sohn","year":"2013","unstructured":"Sohn KM, Peck KR, Joo EJ et al (2013) Duration of colonization and risk factors for prolonged carriage of vancomycin-resistant enterococci after discharge from the hospital. Int J Infect Dis 17(4):e240\u2013e246","journal-title":"Int J Infect Dis"},{"issue":"5","key":"751_CR35","doi-asserted-by":"crossref","first-page":"522","DOI":"10.1001\/archinte.158.5.522","volume":"158","author":"V Stosor","year":"1998","unstructured":"Stosor V, Peterson LR, Postelnick M et al (1998) Enterococcus faecium bacteremia: does vancomycin resistance make a difference? Arch Intern Med 158(5):522\u2013527","journal-title":"Arch Intern Med"},{"key":"751_CR36","unstructured":"The European Committee on Antimicrobial Susceptibility Testing. Breakpoint tables for interpretation of MICs and zone diameters. Published 2017. Version 7.1. Accessed 10 Dec 2018"},{"key":"751_CR37","doi-asserted-by":"crossref","first-page":"297","DOI":"10.1111\/j.1574-695X.2008.00383.x","volume":"52","author":"J Top","year":"2008","unstructured":"Top J, Willems R, Bonten M (2008) Emergence of CC17 Enterococcus faecium: from commensal to hospital-adapted pathogen. FEMS Immunol Med Microbiol 52:297\u2013308","journal-title":"FEMS Immunol Med Microbiol"},{"issue":"8575-6","key":"751_CR38","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/S0140-6736(88)91037-9","volume":"1","author":"AH Uttley","year":"1988","unstructured":"Uttley AH, Collins CH, Naidoo J et al (1988) Vancomycin-resistant enterococci. Lancet 1(8575-6):57\u201358","journal-title":"Lancet"},{"key":"751_CR39","doi-asserted-by":"crossref","first-page":"112","DOI":"10.1186\/1471-2180-7-112","volume":"7","author":"CY Yean","year":"2007","unstructured":"Yean CY, Yin LS, Lalitha P et al (2007) A nanoplex PCR assay for the rapid detection of vancomycin and bifunctional aminoglycoside resistance genes in Enterococcus species. BMC Microbiol 7:112","journal-title":"BMC Microbiol"},{"issue":"1","key":"751_CR40","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.jhin.2018.07.018","volume":"101","author":"M.J. Zhou","year":"2019","unstructured":"Zhou MJ, Li J, Salmasian H et al (2019) The local hospital milieu and healthcare-associated vancomycin-resistant enterococcus acquisition. J Hosp Infect 101(1):69\u201375","journal-title":"Journal of Hospital Infection"}],"container-title":["Folia Microbiologica"],"original-title":[],"language":"en","link":[{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1007\/s12223-019-00751-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/article\/10.1007\/s12223-019-00751-x\/fulltext.html","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"http:\/\/link.springer.com\/content\/pdf\/10.1007\/s12223-019-00751-x.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2020,11,3]],"date-time":"2020-11-03T00:23:29Z","timestamp":1604363009000},"score":1,"resource":{"primary":{"URL":"http:\/\/link.springer.com\/10.1007\/s12223-019-00751-x"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2019,11,4]]},"references-count":40,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2020,6]]}},"alternative-id":["751"],"URL":"https:\/\/doi.org\/10.1007\/s12223-019-00751-x","relation":{},"ISSN":["0015-5632","1874-9356"],"issn-type":[{"type":"print","value":"0015-5632"},{"type":"electronic","value":"1874-9356"}],"subject":[],"published":{"date-parts":[[2019,11,4]]},"assertion":[{"value":"26 March 2019","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"20 September 2019","order":2,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"4 November 2019","order":3,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"order":1,"name":"Ethics","group":{"name":"EthicsHeading","label":"Compliance with ethical standards"}},{"value":"The authors declare that they have no conflict of interest.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"All procedures performed in this study were in accordance with the ethical standards of the institutional research committee (Regional Research Ethics Committee of the University of Debrecen (approval no. 5164-2019) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}}]}}