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4565
symptoms of depression. People in advanced
age with symptoms of depression, cognitive
impairment, multimorbidity, anaemia and total
edentulism should be screened and monitored
for early symptoms of malnutrition.
Key Words:
Malnutrition, MNA-SF, Health-related correlates, El-
derly, Ageing.
Introduction
The imbalance between nutritional needs and nu-
trients intake is more prevalent in older people than
in middle-aged individuals, and malnutrition is a
common condition1. Poor nutritional status (PNS)
not only accelerates the ageing process but may also
increase morbidity and negatively impact the cour-
se of diseases2,3. It may also prolong hospitalization,
increase the costs of treatment and increase the mor-
tality rate among older people4,5. Malnutrition is thus
a signicant factor, which affects the functional in-
dependence of older people6,7.
In view of current demographic projections,
which indicate a rise in the proportion of older
Abstract. – OBJEC TIVE : The aim of the study
was to analyze health-related factors associat-
ed with poor nutritional status (PNS) of a repre-
sentative group of Polish older people, based
on data from the PolSenior project (the rst na-
tion-wide study of Polish senior citizens).
PATIENTS AND METHODS : Nutritional status
was assessed in 3751 community-dwelling older
people (1770 females, mean age: 77.4±8.0 years)
using the Mini Nutritional Assessment - Short
Form. Elements of comprehensive geriatric as-
sessment (cognitive and mood screening), se-
lected medical data were analyzed in relation to
the nutritional status. These were: the number
of medications, the number of chronic diseas-
es, selected diseases potentially related to mal-
nutrition (anaemia, stroke, peptic ulcer, Parkin-
son’s disease, cancer – past or present), total
edentulism, use of dentures, and chronic pain.
RE S ULT S : PNS was observed in 44.2% of par-
ticipants. Female sex [OR 1.72, 95% Cl (1.45-
2.04)], advanced age [OR 2.16 (1.80-2.58)], symp-
toms of depression [OR 11.52 (9.24-14.38)],
cognitive impairment [OR 1.52 (1.20-1.93], multi-
morbidity [OR 1.27 (1.04-1.57)], anaemia [OR 1.80
(1.41-2.29)] and total edentulism [OR 1.26 (1.06-
1.49)] were independently correlated with PNS.
CONCLUSIONS: PNS in Polish elderly pop-
ulation is strongly related to the occurrence of
European Review for Medical and Pharmacological Sciences 2016; 20: 4565-4573
R. KRZYMINSKA-SIEMASZKO1, J. CHUDEK2,3, A. SUWALSKA4, M. LEWANDOWICZ1,
M. MOSSAKOWSKA5, R. KROLL-BALCERZAK6, B. WIZNER7, S. TOBIS8,
K. MEHR9, K. WIECZOROWSKA-TOBIS1,10
1Laboratory of Geriatric Medicine, Department of Palliative Medicine, Poznan University of Medical
Sciences, Poznan, Poland
2Department of Pathophysiology, Medical University of Silesia in Katowice, Katowice, Poland
3Department of Internal Medicine and Oncological Chemotherapy, Medical Faculty, Medical
University of Silesia in Katowice, Katowice, Poland
4Laboratory of Neuropsychobiology, Department of Psychiatry, Poznan University of Medical
Sciences, Poznan, Poland
5International Institute of Molecular and Cell Biology in Warsaw, Warsaw, Poland
6Department of Haematology, Poznan University of Medical Sciences, Poznan, Poland
7Department of Internal Medicine and Gerontology, Jagiellonian University Medical College,
Krakow, Poland
8Laboratory of Occupational Therapy, Department of Geriatrics and Gerontology, Poznan
University of Medical Sciences, Poznan, Poland
9Laboratory of Masticatory System Dysfunctions, Department of Oral Rehabilitation, Poznan
University of Medical Sciences, Poznan, Poland
10Department of Human Nutrition and Hygiene, Poznan University of Life Sciences, Poznan, Poland
Corresponding Author: Roma Krzyminska-Siemaszko, Ph.D; e-mail: romakrzyminska@interia.pl
Health status correlates of malnutrition
in the polish elderly population – Results
of the Polsenior Study
R. Krzyminska-Siemaszko, J. Chudek, A. Suwalska, M. Lewandowicz, M. Mossakowska, et al.
4566
people in most countries worldwide, including
Poland8, it is very important to identify subjects
with PNS early in order to implement proper
treatment. Therefore, efforts to determine the
risk factors that may adversely affect the nutri-
tional status of older people, and which in turn
lead to irreversible changes in their indepen-
dence, seem crucial. However, malnutrition in
old age is usually a multifactorial condition and
it is often not possible to pinpoint its key cause.
Moreover, in cases of coexistence of malnutri-
tion and chronic diseases, it is difcult to deli-
neate the causality.
The socio-demographic correlates of malnutri-
tion in Poland have been presented in a previous
paper9. The authors pointed out that particular
attention should be paid to single, poorly educa-
ted females, especially in advanced age, living in
rural areas and declaring to be in a bad nancial
situation. That paper notwithstanding, data on
health-related correlates of malnutrition from a
representative group of older people are limited
10. The aim of this paper was to, therefore, analy-
ze the health-related factors associated with PNS
in Poland, based on the data from the PolSenior
project – the rst nation-wide study of a represen-
tative group of Polish senior citizens.
Patients and Methods
PolSenior was a multidisciplinary research
project, conducted in 2007-2011, in order to as-
sess the medical, psychological, social and eco-
nomic aspects of ageing in Poland. The aim of the
project was to dene the status of older people as
well as their social and medical needs. The outco-
mes were expected to facilitate the provision of
necessary care in view of the increasing number
of older people.
In the PolSenior project 4979 subjects (2412
females and 2567 males), aged 65 years and ol-
der, were studied. The sample size was calculated
assuming an assessment of traits that occur with
the prevalence of at least 5% within the elderly
population. Participants were selected through a
multi-stage draw, planned so as to obtain a repre-
sentative group for Poland. The selection was per-
formed independently in six 5-year age cohorts:
65-69 years (n=782), 70-74 years (n=923), 75-79
years (n=844), 80-84 years (n=791), 85-89 years
(n=871), 90 years and above (n=768). A detailed
description of the study design has already been
presented11.
Informed consent was obtained from each par-
ticipant or their caregiver prior to the study. The
study was conducted in accordance with the De-
claration of Helsinki and the protocol was appro-
ved by the Bioethics Committee of the Medical
University of Silesia in Katowice (Permit Num-
ber: KNW-6501-38/08).
Studied group
The studied group was comprised of 3751 com-
munity-dwelling respondents of the PolSenior
project (1770 females and 1981 males) who met
the following inclusion criteria:
• Acquired at least 70% of all possible points in
the Mini-Mental State Examination (MMSE);
this result was supposed to conrm the ability
to understand the questions of the 15-point Ge-
riatric Depression Scale (GDS), used to assess
the symptoms of depression,
• Were able to stand upright for height measure-
ment which, in turn, made it possible to calcu-
late Body Mass Index (BMI),
• The data obtained from the respondents enabled
the completion of Mini Nutritional Assessment
– Short Form scale (MNA-SF).
Study Procedure and Data Analysis
In the analysis an assessment of the nutritional
status was made, along with other elements of the
comprehensive geriatric assessment (cognitive
and mood screening) which are important for the
nutritional status. Selected medical history data
was also included (number of medications routi-
nely taken by the study participants, number of
chronic diseases, selected chronic diseases poten-
tially related to malnutrition).
The nutritional status was assessed with the
MNA-SF (the revised MNA-SF of 2009)12, one
of the most valid and frequently used nutritional
screening tools for older people13,14. MNA-SF is
composed of 6 questions and evaluates the decre-
ase in food intake, weight loss, mobility, psycho-
logical stress or acute diseases, neuropsychologi-
cal problems (dementia or depression) and BMI.
Poor nutritional status (PNS) was dened as a
MNA-SF result below 12 points (the maximum is
14 points). Following Kaiser et al15, this included
both subjects with malnutrition (≤7 points) and
those at risk of malnutrition (8-11 points).
Cognitive status was assessed with the Mi-
ni-Mental State Examination (MMSE)16. A result
of 24-30 points indicated that there was no de-
mentia. Results of 0-23 points were classied as
a positive screening for dementia (20-23 points:
Health status correlates of malnutrition in Poland
4567
mild dementia, 10-19: points: moderate dementia
and 0-9 points: severe dementia).
The presence of the symptoms of depression
was assessed by means of a short version of Ge-
riatric Depression Scale (GDS), composed of 15
questions17. GDS was performed only for those
respondents who obtained at least 70% of all pos-
sible points in MMSE (n=3984), thus excluding
persons with cognitive impairment (who might,
therefore, not fully understand the questions).
Subjects with at least 6 points on the GDS sca-
le were classied as belonging to the group with
symptoms of depression.
The number of medications taken by the re-
spondents came from interviews conducted by
trained nurses with the older people or their care-
givers (if the respondents were not able to actively
participate in the project due to health problems or
disability, e.g. hearing loss). They were asked to
present all medications being used. The analysis
included medications taken at least once a week,
both prescribed and over-the-counter (OTC).
With regard to the number of medications, the re-
spondents were divided into two groups: without
polypharmacy (up to 4 medications taken simul-
taneously) and with polypharmacy (at least 5 me-
dications).
The data on the number of diseases were also
obtained during the interviews. Subjects with
fewer than 4 chronic diseases were compared
against those with 4 or more diseases (i.e. with
multimorbidity). The data on selected chronic
diseases potentially related to malnutrition (ana-
emia - based on WHO denition: haemoglobin
below 12 g/dl in females and 13 g/dl in males, the
peptic ulcer, stroke – both ischemic and haemor-
rhagic, Parkinson’s disease and cancer – present
or past) were also collected. Additionally, chronic
pain was evaluated, dened as persisting longer
than 3 months.
The respondents were also classied based on
their dental status. They were divided into those
with total edentulism (no teeth of their own) and
those who used dentures. Those who had articial
dentures were analyzed separately.
Statistical Analysis
Statistical analysis was performed with STA-
TISTICA 10.0 software (StatSoft, Poland). For
all the analyzed variables the mean and standard
deviations were calculated. Data distribution nor-
mality was assessed using Shapiro-Wilk’s test.
Statistical comparisons between the groups were
made using Chi-square test. To assess simulta-
neous interdependence between many variables,
multiple regression (logistic regression) was used,
specifying the odds ratio and the condence inter-
val with the condence limit of 95%; p<0.05 was
considered statistically signicant.
The sample was intended to include the same
number of men and women in all age cohorts. It
thus allowed for the precise assessment of studied
factors in the oldest groups. On the other hand, ol-
der groups and males were overrepresented com-
pared to the actual population structure. Conse-
quently, post-stratication was necessary in order
to make the sample representative of the Polish
population and assure that the results reected the
distribution of studied characteristics (including
malnutrition and risk of malnutrition) in the entire
population of older people in Poland.
Results
Study Participants Characteristics
The mean age of the study participants was
77.4±8.0 years. The female to male ratio was 9:10
(47.2% of subjects studied were females).
Among analyzed individuals 22.8% were dia-
gnosed with at least 4 chronic diseases, 43.8%
were treated with at least 5 medications simulta-
neously and 10.9% with at least 10 medications.
Screening for dementia was positive in 17.1% of
the individuals studied, and in 29.0% symptoms
of depression were present.
Anaemia was present in 14.9% of individuals,
peptic ulcer was declared by 10.2%, stroke by
6.4% and Parkinson’s disease by 2.1%. 6.7% of
the studied population reported being diagnosed
with cancer (at present or in the past). Chronic
pain was present in 42.6% of the respondents. To-
tal edentulism was found in 47.8%; only 77.6% of
participants had dentures and only 83.7% of den-
ture owners used them. Table I presents the de-
mographic and health characteristics of the study
participants by gender.
Factors Associated with Poor
Nutritional Status
PNS was found in 44.2% of studied subjects,
including 6.2% who were malnourished, and
38.0% at risk of malnutrition.
Table II shows the impact of health-related fac-
tors (including age and sex) on the prevalence of
PNS using univariable analysis. Age and sex had
a strong impact on PNS. PNS was detected almost
twice as frequently in subjects of the oldest cohort
R. Krzyminska-Siemaszko, J. Chudek, A. Suwalska, M. Lewandowicz, M. Mossakowska, et al.
4568
than in the youngest one (p<0.001) and was more
frequent among females than males (p<0.001).
Respondents exposed to a higher risk of PNS in-
cluded those who were diagnosed with at least 4
chronic diseases (p<0.001) as well as those with
polypharmacy (p<0.001).
As far as analyzed clinical conditions are con-
cerned, the factors contributing to PNS included
Table I. Demographics and health characteristics of the participants by gender.
Males Females
Variable n (%) n (%) p
Age
65-69 years 344 (17.4) 378 (21.4)
70-74 years 429 (21.7) 406 (22.9)
75-79 years 373 (18.8) 329 (18.6) p=0.007*
80-84 years 320 (16.2) 272 (15.4)
85-89 years 326 (16.5) 244 (13.8)
90 and over 189 (9.5) 141 (8.0)
Number of chronic diseases
≥ 4 diseases 358 (18.1) 498 (28.1) p<0.001
< 4 diseases 1623 (81.9) 1272 (71.9)
Number of medications
0-4 970 (49.6) 706 (40.5)
5-9 810 (41.4) 810 (46.4) p<0.001*
10 or more 176 (9.0) 228 (13.1)
Dementia
Yes 314 (15.8) 328 (18.5) p<0.05
No 1667 (84.2) 1442 (81.5)
Depression
Yes 471 (23.8) 618 (34.9) p<0.001
No 1510 (76.2) 1152 (65.1)
Anaemia
Yes 300 (18.1) 165 (11.3) p<0.001
No 1358 (81.9) 1291 (88.7)
Peptic ulcer
Yes 215 (11.0) 164 (9.3) ns
No 1746 (89.0) 1593 (90.7)
Stroke
Yes 127 (6.4) 111(6.3) ns
No 1850 (93.6) 1653 (93.7)
Parkinson’s disease
Yes 49 (2.5) 29 (1.7) ns
No 1919 (97.5) 1728 (98.3)
Cancer
Yes 136 (6.9) 115 (6.5) ns
No 1835 (93.1) 1642 (93.5)
Chronic pain (> 3 months)
Yes 714 (36.1) 880 (49.8) p<0.001
No 1263 (63.9) 886 (50.2)
Total edentulism
Yes 839 (43.9) 895 (52.1) p<0.001
No 1072 (56.1) 822 (47.9)
Use of dentures
Yes 1302 (66.3) 1402 (79.6) p<0.001*
No 106 (5.4) 79 (4.5)
Doesn’t have any 555 (22.3) 281 (15.9)
Chronic pain (> 3 months)
Yes 714 (36.1) 880 (49.8) p<0.001
No 1263 (63.9) 886 (50.2)
Notes: *X2 for trend
Health status correlates of malnutrition in Poland
4569
positive screening for dementia and symptoms of
depression (p<0.001) as well as reports on chronic
pain (p<0.001). Moreover, PNS was more frequent
in study participants with anaemia (p<0.001),
peptic ulcer (p<0.01), stroke (p<0.001), Parkin-
son’s disease (p<0.001) and cancer (p<0.05).
PNS was more frequently diagnosed in older
people with total edentulism (p<0.001). In all
the studied groups a comparison of subjects who
used dentures with those who did not use them
(regardless of whether they still had their own te-
eth or were toothless) revealed no statistical dif-
ference in the risk of PNS. However, in the case
of subjects with total edentulism, PNS was more
frequent in those who did not use dentures (66.2%
vs. 53.0%; p<0.001).
The multiple regression models including all fac-
tors inuencing the risk of PNS from the univariable
analysis is presented in Table III. The strongest in-
dependent correlate of PNS in the population stu-
died was the presence of symptoms of depression
(OR 11.52). Female sex, advanced age (80 years or
more), positive screening for dementia, multimorbi-
dity (the presence of 4 or more diseases), anaemia,
and total edentulism were also found to be indepen-
dent factors contributing to PNS.
Separately analyzed multiple regression models
for females and males showed differences in the
correlates of PNS (Table III). For both sexes, the
common correlates included: advanced age (80 ye-
ars or more), the presence of symptoms of depres-
sion and positive screening for dementia, as well as
Table II. Poor nutrition status (MNA-SF<12) of the participants by socio-demographic and health characteristics
Poor nutritional status
Variable Level n (%) p
Sex Males [n=1981] 828 (41.8) p<0.001
Females [n=1770] 1009 (57.0)
Age 65-69 years [n=722] 272 (37.7)
70-74 years [n=835] 313 (37.5)
75-79 years [n=702] 328 (46.7) p<0.001*
80-84 years [n=592] 328 (55.4)
85-89 years [n=570] 356 (62.5)
90 and over [n=330] 240 (72.7)
Number of chronic diseases ≥ 4 diseases [n=856] 507 (59.2)
< 4 diseases [n=2895] 1330 (45.9) p<0.001
Number of medications 0-4 [n=1676] 746 (44.5)
5-9 [n=1620] 814 (50.2) p<0.001*
10 or more [n=404] 248 (61.4)
Dementia Yes [n=642] 419 (65.3) p<0.001
No [n=3109] 1418 (45.6)
Depression Yes [n=1089] 938 (86.1)
No [n=2662] 899 (33.8) p<0.001
Anaemia Yes [n=465] 289 (62.2)
No [n=2649] 1202 (45.4) p<0.001
Peptic ulcer Yes [n=379] 210 (55.4)
No [n=3339] 1608 (48.2) p<0.01
Stroke
Yes [n=238] 150 (63.0)
No [n=3503] 1681 (48.0) p<0.001
Parkinson’s disease Yes [n=78] 53 (67.9)
No [n=3647] 1767 (48.5) p<0.001
Cancer Yes [n=251] 138 (55.0) p<0.05
No [n=3477] 1685 (48.5)
Chronic pain Yes [n=1594] 862 (54.1)
No [n=2148] 971 (45.2) p<0.001
Total edentulism Yes [n=1734] 955 (55.1)
No [n=1894] 822 (43.4)
Use of dentures Yes [n=2704] 1304 (48.2) p<0.001
No [n=185] 102 (55.1) ns
Notes: *X2 for trend.
R. Krzyminska-Siemaszko, J. Chudek, A. Suwalska, M. Lewandowicz, M. Mossakowska, et al.
4570
anaemia. In males, PNS was also related to edentu-
lism, whereas in females – to multimorbidity.
Discussion
The paper presents health-related correlates of
PNS among a representative population of Poland.
In addition to advanced age (80 years or more)
and female sex, the presence of symptoms of de-
pression, positive screening for dementia, multi-
morbidity (4 or more chronic diseases), anaemia
and total edentulism were independent correlates
of PNS in the Polish population.
A shortened version of the MNA (the revised
MNA-SF of 2009) was used instead of its full
version as it allows prompt and efcient identi-
cation of those older people who are malnouri-
shed or are at a greater risk of malnutrition. The
MNA-SF requires less time to complete than the
full version, which is advantageous, especially in
studies of the elderly population. The high sen-
sitivity and specicity of the MNA-SF scale, as
well as its good correlation with the full version,
have been conrmed in many clinical studies18,19.
The MNA-SF scale has also been validated in re-
search among community-dwelling older people
in Poland20.
In previous investigations1,10,21-24 of the aspects
associated with malnutrition in older people, va-
rious health-related factors have been taken into
consideration, based on multidimensional analy-
sis. With the exception of Nykanen et al10, de-
pression was included in all of them. In our work,
symptoms of depression were the strongest cor-
relate of PNS. This nding is in agreement with
previously published data1,21,23-24, although Torres
et al22 observed the relationship between PNS and
depression only in older people living in urban
areas. Among the symptoms of depression apathy,
loss of appetite, and loss of interest in self-care
were shown to increase the risk of malnutrition1,21.
On the other hand, vitamin and antioxidant de-
ciencies have been proven to reduce the risk of
depression25. Thus, malnutrition and depression
may accelerate each other.
Similarly to other studies1,10,22-24, lower results
of MMSE also contributed to PNS in the PolSe-
nior population. It has been stressed that subjects
with dementia may be unable to not only go shop-
ping and prepare meals, but even eat properly.
Additionally, among individuals with dementia,
abnormal food-related behaviours are quite com-
mon26 and may lead to unintentional weight loss
26,27 as well as PNS.
Boulos et al23 have presented the vicious circle
between malnutrition and multimorbidity. In this
study, multimorbidity was an important factor con-
tributing to PNS. It has been shown that various
chronic diseases are accompanied by decreased
food intake and metabolic changes, with a subse-
quent negative impact on the energy balance23,31.
Among the diseases included in our report only
anaemia (which is itself frequently a symptom of
chronic diseases and malnutrition) was found to
be a factor for PNS. Mitrache et al32 have shown
that malnutrition may play an important etiologic
role in anaemia in older people. Moreover, Ramel
et al33 have found that measures related to mal-
nutrition, e.g. midarm muscle circumference and
prealbumin concentration, remained signicant
predictors of haemoglobin in hospitalised older
patients in Ireland. In this context, however, it is
worth noticing that anaemia is not included in the
list of diseases related to malnutrition presented in
the review of Hickson et al31.
In the present study, peptic ulcer, stroke, Par-
kinson’s disease and cancer were not independent
Table III. Factors associated with poor nutritional status (multiple logistic regression, backward selection model).
Overall Males Females
Variable OR (95% Cl) p OR (95% Cl) p OR (95% Cl) p
Female sex 1.72 (1.45-2.04) <0.001 - -
Age* 2.16 (1.80-2.58) <0.001 1.78 (1.40-2.27) <0.001 2.77 (2.11-3.61) <0.001
Depression 11.52 (9.24-14.38) <0.001 12.80 (9.40-17.43) <0.001 10.80(7.85-14.87) <0.001
Dementia 1.52 (1.20-1.93) <0.001 1.58 (1.15-2.18) 0.005 1.41 (0.99-2.02) 0.05
Multimorbidity** 1.27 (1.04-1.57) 0.02 - - 1.35 (1.01-1.79) 0.04
Anaemia 1.80 (1.41-2.29) <0.001 1.81(1.34-2.44) <0.001 1.99 (1.30-3.07) 0.002
Total edentulism 1.26 (1.06-1.49) 0.009 1.31(1.04-1.66) 0.02 - -
Notes: *80 years or more; **4 or more diagnosed diseases.
Health status correlates of malnutrition in Poland
4571
factors related to PNS. Other scholars10,22 have not
included these parameters. Malnutrition is a com-
mon problem in patients with malignancy, but it
mainly occurs in advanced stages of cancer34,35.
Among subjects who had a stroke and Parkinson’s
disease, malnutrition is related to disability36,37. In
the entire PolSenior population the number of stu-
dy participants with advanced stages of analyzed
diseases was relatively small. As far as peptic ul-
cers are concerned, it has been shown that symp-
toms such as stomach pain (and not the diagnosis
itself) were related to malnutrition24.
Dental status is an integral part of the well-
being of older people. Poor dental status in old
age, either edentulism or lack of dentures, is a risk
factor of malnutrition that is well documented in
the literature28,29. It is also emphasized that a lack
of functional dentition is associated with avoiding
foods that must be chewed, such as meat. Raw ve-
getables, fruit, and high-bre foods are also avoi-
ded28. Such a diet alone may result in malnutrition.
Chronic pain was not an independent factor of
PNS in the PolSenior population. It has only been
included in a multivariable analysis of factors as-
sociated with PNS performed in a rural area in Le-
banon, by Boulos et al23, who showed that older
people complaining of chronic pain were almost
twice as likely to have PNS. It seems possible that
chronic pain may cause mood alterations38 and,
subsequently, symptoms of depression (not pain)
constitute an independent factor of PNS.
The use of a greater number of medications in
the PolSenior population was not related to PNS.
This is in agreement with the data published by
van Bokhorst et al1. On the other hand, Torres et
al22 have reported an association between a higher
number of medications used daily and PNS. It
seems possible that this is at least partly due to
different denitions of polypharmacy used by the
cited authors.
When a multiple regression analysis was per-
formed independently for females and males,
multimorbidity in the former and edentulism in
the latter was found to be independent risk fac-
tors for PNS. This is possibly a new observation.
It has also been shown that females and males age
differently, which most likely also affects the cor-
relates of PNS39.
Conclusions
PNS in the Polish elderly population is strongly
related to the occurrence of symptoms of depres-
sion. In particular, people in advanced age with
symptoms of depression, those with a positive
screening for dementia, with multimorbidity, ana-
emia and total edentulism should be screened and
monitored for early symptoms of malnutrition.
Proper nutritional interventions for older people
with early symptoms of malnutrition are a major
challenge not only for nutritional specialists, phy-
sicians, and nurses but also for all public health
practitioners.
Acknowledgements
Implemented under publicly-funded project No. PBZ-
MEIN-9/2/2006, Ministr y of Science and Higher Ed-
ucation.
Conflicts of interest
The authors declare no conicts of interest.
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