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\title{Establishment Local Reference of Spleen Length in Sudanese Normal School Age Children Sonographically}
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             \author[1]{Caroline Edward  Ayad}

             \author[2]{Maha  Nouri}

             \affil[1]{  Sudan University of Science and Technology}

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\date{\small \em Received: 6 December 2012 Accepted: 5 January 2013 Published: 15 January 2013}

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\begin{abstract}
        


The objectives of this study were to establish a local ultrasonic splenic length which can be used as reference for Sudanese healthy school age children and to determine the normal standards spleen length related to gender, age, body weight, height, body mass index (BMI), and abdominal circumference.Methods: 215 healthy school-aged children (7-13 years) from city centers were evaluated. Gender, age, weight, height, BMI, and abdominal circumference were determined for each case. The sonographic examination for spleen length was performed with a high resolution real time scanner (SSD-500 Aloka Medical System) fitted with a 3.5MHz convex transducer; all of the measured spleens had a normal position, shape, and echo texture. The children were classified into 7groups according to age and gender. Results:The mean length of the spleen was found to be 9.5-10.4cm.There was significant difference between the spleen length in males and females (P-value 0.000), the mean length of spleen in females is greater than in males. A significant relation was found between spleen length and age, weight, height, abdomen circumference and BMI.

\end{abstract}


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\let\tabcellsep& 	 	 		 
\section[{Introduction}]{Introduction}\par
he spleen is the largest organ in the reticulo endothelial system. Spleen size can be used as an indicator of disease activity in a variety of disorders of the reticulo endothelial system. \hyperref[b0]{[1]} The spleen responds to different pathologic states by dimensional changes. Malaria and sickle cell disease with a geographical bias are known to cause changes in spleen size. A rapid increase in spleen size, secondary to sequestration of red blood cells, platelets and other haematological elements, was observed in neonates on extracoporal membrane oxygenation \hyperref[b1]{[2,}\hyperref[b2]{3,}\hyperref[b3]{4]} There are several studies about normal internal organs character  {\ref [5,} {\ref 6]} All of these are from the populations of Caucasoid and from the populations of Asian, Japan, China, Korea, and India. In the past, Thailand normally used references from American or European references. The problem is that the differences of these factors make the indicators different: race, body structure, genetic, environment, living condition, life style, and food.  {\ref [7,}\hyperref[b5]{8]}. Spleen size varies widely according to age also many diseases can affect its size, including infections and malignancy. \hyperref[b6]{[9,}\hyperref[b7]{10]} . The variations in the anthropometric features of various populations, races and regions are an established fact. The climate of the zone and the socioeconomic status of Sudan, make the population of this region special. There is no comprehensive anthropometric study on the normal measurements of spleen by ultrasonography in Sudanese, and therefore, it was thought to be important to undertake the present study to evaluate the normal measurements of spleen in the school age Sudanese population. 
\section[{II.}]{II.} 
\section[{Materials and Methods}]{Materials and Methods} 
\section[{Volume XIII Issue II Version I}]{Volume XIII Issue II Version I}
\begin{quote}
Year\end{quote}
\par
Abstract-Objectives: The objectives of this study were to establish a local ultrasonic splenic length which can be used as reference for Sudanese healthy school age children and to determine the normal standards spleen length related to gender, age, body weight, height, body mass index (BMI), and abdominal circumference.\par
Methods: 215 healthy school-aged children (7-13 years) from city centers were evaluated. Gender, age, weight, height, BMI, and abdominal circumference were determined for each case. The sonographic examination for spleen length was performed with a high resolution real time scanner (SSD-500 Aloka Medical System) fitted with a 3.5MHz convex transducer; all of the measured spleens had a normal position, shape, and echo texture. The children were classified into 7groups according to age and gender.\par
Results: The mean length of the spleen was found to be 9.5-10.4cm.There was significant difference between the spleen length in males and females (Pvalue 0.000), the mean length of spleen in females is greater than in males. A significant relation was found between spleen length and age, weight, height, abdomen circumference and BMI . 
\section[{Conclusion:}]{Conclusion:}\par
The spleen length obtained in this study was in different range of values reported in previous studies and a local reference of spleen length was established. We hope that this study contributes to daily clinical practice in ultrasound clinics for interpretation of sonographic examinations for Sudanese school age children regarding the spleen length.\par
Radiography and radionuclide studies expose the patient to X and gamma radiation \hyperref[b7]{[10,}\hyperref[b8]{11,}\hyperref[b9]{12,}\hyperref[b10]{13]}. Ultrasonography is the method of choice for the diagnosis of the abdominal pathologies \hyperref[b11]{[14]}. Sonography is routinely used to determine the internal structures of the body because the examination is real time, three-dimensional and independent of organ function .Ultrasonography is a non-invasive, established, safe, quick and accurate method for the measurement of spleen size. \hyperref[b10]{[13]} In Sudan, There is absence of domestic reference for spleen length; and as far as we know, no study was published in the open literature, regarding the spleen length for school age children therefore, the importance of this study lies in finding the normal length of spleen and to determine its correlation with gender, age, height, weight, body mass index (BMI) and abdominal circumference.  
\section[{Results}]{Results} 
\section[{a) Ultrasound Machine}]{a) Ultrasound Machine}\par
The sonographic examination performed with a high resolution real time scanner (SSD-500 Aloka Medical System Co, Ltd, Tokyo, Japan) with a 3.5MHz convex transducer. 
\section[{b) Sample}]{b) Sample}\par
A total of 215 (104 males, 111 females) healthy Sudanese children with normal spleen position, shape and echo texture. Any abnormal spleen position, shape and echo texture, children affected with malaria, malignant spleen diseases, benign spleen conditions, traumatic spleen were excluded. 
\section[{c) Measurement Technique for spleen}]{c) Measurement Technique for spleen}\par
Spleen Length was taken by measuring the longest dimension in coronal plane. Longitudinal dimensions in the coronal plane were obtained with the subject in supine or slightly right lateral decubitus position; longitudinal size measurement was performed between the most supero medial and the most infero lateral points of the spleen.   5. Ludwig J. Current methods of autopsy practice. Philadelphia: Saunders; 1979: 647-89. 
\section[{From above table (6) it was noticed that all p-values are less than 0.05 that means that there is relationship between the variables. The Pearson Correlation denotes values of the correlation either positive (+) or negative (-) as follows:}]{From above table (6) it was noticed that all p-values are less than 0.05 that means that there is relationship between the variables. The Pearson Correlation denotes values of the correlation either positive (+) or negative (-) as follows:}\par
IV. 
\section[{Discussion}]{Discussion}\par
Ultrasound is simple and reliable in measuring the abdominal visceral organs without the risk of ionizing radiation. Measuring the volume is time-consuming and impractical in daily use and the longitudinal measuring of these organs is used as part of routine abdominal sonographic scanning for purposes of determining the normal anatomy \hyperref[b12]{[15]}. Therefore, the longitudinal measurement was used because it is more practically considered.\par
The length of the spleen is an adequate indicator of size for most purposes and provides a useful baseline for monitoring changes in disease status. Establishing normal parameters is mandatory for defining the pathologic changes in size of the spleen, in routine sonographic examinations of children. \hyperref[b12]{[15]} This study included 104(48.4\%) males, 111(51.6\%) females of school children with ages from 7 up to 13.When measuring the spleen;28 out of 215 (13.0\%)got spleen length of 6.5-7.7 cm,43(20\%)of 5-8.4cm, 56(26\%) of 8.5-9.4cm,67(31.2\%)of 9.5-10.4 and measurements greater than 10.5 were found in 21(9.8) of the sample, The mean spleen measurement was found to be 9.0 ±1.2 (max11.7, min6.7),normal spleen has been investigated by only a few researchers  {\ref [16]}.When comparing our results with other similar results ,we found that Sudanese children have less length than USA in all group of ages but greater than Greek [16], Indian \hyperref[b14]{[17]} and Turkish populations \hyperref[b15]{[18]} When comparing the spleen length measurement with age in all group of ages it was found to be 7.9,7.7,8.9,9.3,9.4,9.9,10.1,9.0 cm for the ages 7,8,9,10,11,12,13 respectively and the relation is significant between the spleen length and this group of children ages at p value 0.000.\par
DeLand \hyperref[b16]{[19]} stated that the spleen showed variation according to sex and age. He reported that spleen in females was smaller than males in all age groups. But Niederau et al. \hyperref[b17]{[20]} in their sonographic study, which was carried out on adults, found that spleen size decreased with increasing age.\par
In our study a significant difference was detected between males and females in spleen length and abdomen circumference measurements because Pvalue was found to be less than 0.05, that means the mean measurements values of spleen and abdomen circumference in females are greater than males and were found to be 9.3 ± 1.1 and 59.3 ± 8.1, 8.7 ± 1.1and 57.2 ± 5.6 respectively .\par
The study showed that the BMI, height, weight abdominal circumference have significant relation with the spleen length in all these group of ages.\par
From table (6) we noticed that all p-values are less than 0.05, that means there is a relationship between the variables. The Pearson Correlation denotes value of the correlation either positive (+) or negative (-) as follows: 0.90 -1.00 very strong relationship, 0.70 -0.89 strong relationship, 0.50 -0.69 middle relationship, 0.00 -0.49 weak relationship.\par
Scatter plot diagrams showed the linear relationship between spleen length measured in (cm) and females and males, BMI, abdomen circumference (AC) and age respectively. The equations showed that the for BMI and AC ,the spleen length was increased proportionally and by applying the following equations the spleen length can be estimated for these group of ages and known BMI and AC as :\par
For female Spleen length (cm) =(0.432 X Age) + 5.024 . For male Spleen length (cm) =(0.384 X Age) + 4.827. For female Spleen length (cm) =(0.172 X BMI) + 6.368,For male Spleen length (cm) =(0.209X BMI) + 5.182,For female Spleen length (cm) =(0.083 X AC) + 4.320,For male Spleen length (cm) =(0.089X AC) + 3.546.\par
In conclusion, the spleen length obtained in this study was in different range of values reported in the previous studies. The mean spleen length in females is greater than males .\par
By applying the above equations the spleen length can be estimated. A local reference of spleen length was established; further studies are required to establish national reference of spleen length and volume in Sudan for both children and adults.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
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\noindent\textbf{1}\includegraphics[]{image-3.png}
\caption{\label{fig_1}Figure 1 :}\end{figure}
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\noindent\textbf{2}\includegraphics[]{image-4.png}
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\noindent\textbf{1} \par 
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Year\tabcellsep \tabcellsep \tabcellsep \tabcellsep Spleen\tabcellsep \tabcellsep \multicolumn{2}{l}{Frequency}\tabcellsep \tabcellsep \multicolumn{2}{l}{Percentage}\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep 6.5-7.4\tabcellsep \tabcellsep 28\tabcellsep \tabcellsep \tabcellsep \tabcellsep 13.0\%\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep 7.5-8.4\tabcellsep \tabcellsep 43\tabcellsep \tabcellsep \tabcellsep \tabcellsep 20.0\%\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep 8.5-9.4\tabcellsep \tabcellsep 56\tabcellsep \tabcellsep \tabcellsep \tabcellsep 26.0\%\\
Volume XIII Issue II Version I\tabcellsep \multicolumn{2}{l}{Mean Std. Deviation Minimum Maximum}\tabcellsep \multicolumn{2}{l}{9.5-10.4 ? 10.5 Total BMI 16.8 ±3.4 10.4 33.6}\tabcellsep Weight (Kg) 32.5 ±10.1 16.0 71.0\tabcellsep 67 21 215\tabcellsep \multicolumn{3}{l}{Abdominal circumference 58.2 ±7.1 43.0 83.0}\tabcellsep 31.2\% 9.8\% 100.0\% Height (M) 137.9 ±11.0 112.0 167.0\tabcellsep Spleen (cm) 9.0 ±1.2 6.7 11.7\\
( ) D\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{Variable}\tabcellsep 7\tabcellsep \tabcellsep 8\tabcellsep 9\tabcellsep Age 10\tabcellsep \tabcellsep 11\tabcellsep 12\tabcellsep 13\tabcellsep Total\tabcellsep P-Value\\
BMI\tabcellsep \tabcellsep 14.4\tabcellsep \tabcellsep 14.7\tabcellsep 18.0\tabcellsep 17.0\tabcellsep \tabcellsep 16.7\tabcellsep 18.1\tabcellsep 18.9\tabcellsep 16.8\tabcellsep 0.000*\\
\tabcellsep \tabcellsep ± 2.0\tabcellsep \tabcellsep ± 2.2\tabcellsep ± 4.5\tabcellsep ± 2.8\tabcellsep \tabcellsep ± 2.7\tabcellsep ± 2.9\tabcellsep ± 3.6\tabcellsep ± 3.4\\
\multicolumn{2}{l}{Weight}\tabcellsep 22.9\tabcellsep \tabcellsep 24.1\tabcellsep 32.9\tabcellsep 33.1\tabcellsep \tabcellsep 33.5\tabcellsep 38.8\tabcellsep 44.5 ±\tabcellsep 32.5\tabcellsep 0.000*\\
\tabcellsep \tabcellsep ± 3.6\tabcellsep \tabcellsep ± 4.8\tabcellsep ± 9.3\tabcellsep ± 7.5\tabcellsep \tabcellsep ± 6.0\tabcellsep ± 7.7\tabcellsep 10.2\tabcellsep ± 10.1\\
\multicolumn{2}{l}{Abdominal}\tabcellsep 53.9\tabcellsep \tabcellsep 53.5\tabcellsep 60.2\tabcellsep 59.3\tabcellsep \tabcellsep 58.8\tabcellsep 59.1\tabcellsep 63.8 ±\tabcellsep 58.2\tabcellsep 0.000*\\
\multicolumn{2}{l}{circumference}\tabcellsep ± 4.1\tabcellsep \tabcellsep ± 5.2\tabcellsep ± 8.5\tabcellsep ± 6.4\tabcellsep \tabcellsep ± 5.3\tabcellsep ± 6.8\tabcellsep 7.1\tabcellsep ± 7.1\\
\multicolumn{2}{l}{Height}\tabcellsep \multicolumn{2}{l}{126.1 ±}\tabcellsep 127.6 ±\tabcellsep 134.7 ±\tabcellsep 139.0 ±\tabcellsep \multicolumn{2}{l}{141.4 ±}\tabcellsep 146.0 ±\tabcellsep 152.8 ±\tabcellsep 137.9 ±\tabcellsep 0.000*\\
\tabcellsep \tabcellsep 5.5\tabcellsep \tabcellsep 5.4\tabcellsep 4.3\tabcellsep 7.4\tabcellsep \tabcellsep 5.1\tabcellsep 6.5\tabcellsep 8.9\tabcellsep 11.0\\
\multicolumn{2}{l}{Spleen}\tabcellsep 7.9\tabcellsep \tabcellsep 7.7\tabcellsep 8.9\tabcellsep 9.3\tabcellsep \tabcellsep 9.4\tabcellsep 9.9\tabcellsep 10.1 ±\tabcellsep 9.0\tabcellsep 0.000*\\
\tabcellsep \tabcellsep ± 0.7\tabcellsep \tabcellsep ± 0.6\tabcellsep ± 1.3\tabcellsep ± 0.8\tabcellsep \tabcellsep ± 0.6\tabcellsep ± 0.7\tabcellsep 0.7\tabcellsep ± 1.2\\
\tabcellsep \multicolumn{2}{l}{Variable}\tabcellsep \tabcellsep \tabcellsep Male\tabcellsep \multicolumn{2}{l}{Gender}\tabcellsep Female\tabcellsep \tabcellsep Total\tabcellsep P-Value\\
\tabcellsep \tabcellsep BMI\tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{16.6 ± 2.3}\tabcellsep \tabcellsep \multicolumn{2}{l}{16.9 ± 4.2}\tabcellsep 16.8 ± 3.4\tabcellsep 0.580\\
\tabcellsep \tabcellsep Weight\tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{31.6 ± 7.8}\tabcellsep \multicolumn{3}{l}{33.4 ± 11.8}\tabcellsep 32.5 ± 10.1\tabcellsep 0.195\\
\tabcellsep \multicolumn{4}{l}{Abdominal circumference}\tabcellsep \multicolumn{2}{l}{57.2 ± 5.6}\tabcellsep \tabcellsep \multicolumn{2}{l}{59.3 ± 8.1}\tabcellsep 58.2 ± 7.1\tabcellsep 0.029*\\
\tabcellsep \tabcellsep Height\tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{136.9 ± 10.5}\tabcellsep \multicolumn{3}{l}{138.8 ± 11.4}\tabcellsep 137.9 ± 11.0\tabcellsep 0.203\\
\tabcellsep \tabcellsep Spleen\tabcellsep \tabcellsep \tabcellsep \multicolumn{2}{l}{8.7 ± 1.1}\tabcellsep \tabcellsep 9.3 ± 1.1\tabcellsep \tabcellsep 9.0 ± 1.2\tabcellsep 0.000*\end{longtable} \par
  {\small\itshape [Note: Establishment Local Reference of Spleen Length in Sudanese Normal School Age Children Sonographically]} 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_2}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.06780898876404494\textwidth}P{0.07258426966292135\textwidth}P{0.13752808988764043\textwidth}P{0.14134831460674158\textwidth}P{0.15471910112359552\textwidth}P{0.14707865168539325\textwidth}P{0.12893258426966292\textwidth}}
Age\tabcellsep Gender\tabcellsep BMI*\tabcellsep Weight\tabcellsep Abdomen circumference\tabcellsep Height\tabcellsep Spleen\\
7\tabcellsep Male\tabcellsep 15.6 ± 1.8\tabcellsep 23.7 ± 3.4\tabcellsep 53.5 ± 4.1\tabcellsep 123.7 ± 6.9\tabcellsep 8.0 ± 0.8\\
\tabcellsep Female\tabcellsep 13.6 ± 1.7\tabcellsep 22.3 ± 3.7\tabcellsep 54.3 ± 4.2\tabcellsep 127.9 ± 3.5\tabcellsep 7.9 ± 0.5\\
8\tabcellsep Male\tabcellsep 15.7 ± 1.6\tabcellsep 26.0 ± 3.7\tabcellsep 54.3 ± 3.1\tabcellsep 128.4 ± 5.7\tabcellsep 7.5 ± 0.6\\
\tabcellsep Female\tabcellsep 13.7 ± 2.3\tabcellsep 22.1 ± 5.2\tabcellsep 52.7 ± 6.8\tabcellsep 126.8 ± 5.1\tabcellsep 7.8 ± 0.5\\
9\tabcellsep Male\tabcellsep 16.5 ± 1.6\tabcellsep 29.5 ± 3.9\tabcellsep 57.1 ± 4.9\tabcellsep 133.7 ± 4.5\tabcellsep 7.9 ± 0.7\\
\tabcellsep Female\tabcellsep 19.6 ± 5.9\tabcellsep 36.3 ± 11.8\tabcellsep 63.3 ± 10.3\tabcellsep ± 4.1\tabcellsep 9.9 ± 0.9\\
10\tabcellsep Male\tabcellsep 16.7 ± 2.2\tabcellsep 31.9 ± 4.3\tabcellsep 58.7 ± 4.3\tabcellsep 138.1 ± 5.8\tabcellsep 8.6 ± 0.4\\
\tabcellsep Female\tabcellsep 17.3 ± 3.3\tabcellsep 34.2 ± 9.7\tabcellsep 59.9 ± 8.1\tabcellsep 140.0 ± 8.9\tabcellsep 10.0 ± 0.3\\
11\tabcellsep Male\tabcellsep 16.1 ± 2.2\tabcellsep 32.3 ± 5.5\tabcellsep 57.3 ± 4.5\tabcellsep 141.3 ± 5.8\tabcellsep 9.2 ± 0.7\\
\tabcellsep Female\tabcellsep 17.3 ± 3.0\tabcellsep 34.7 ± 6.4\tabcellsep 60.4 ± 5.7\tabcellsep 141.5 ± 4.6\tabcellsep 9.5 ± 0.3\\
12\tabcellsep Male\tabcellsep 18.3 ± 3.2\tabcellsep 37.8 ± 8.3\tabcellsep 57.8 ± 6.8\tabcellsep 143.2 ± 4.4\tabcellsep 9.7 ± 1.0\\
\tabcellsep Female\tabcellsep 18.0 ± 2.7\tabcellsep 39.8 ± 7.2\tabcellsep 60.3 ± 6.8\tabcellsep 148.6 ± 7.2\tabcellsep 10.0 ± 0.3\\
13\tabcellsep Male\tabcellsep 17.7 ± 2.4\tabcellsep 40.3 ± 8.5\tabcellsep 61.5 ± 7.0\tabcellsep 150.3 ± 9.7\tabcellsep 9.8 ± 0.7\\
\tabcellsep Female\tabcellsep 20.2 ± 4.3\tabcellsep 48.6 ± 10.3\tabcellsep 66.1 ± 6.6\tabcellsep 155.3 ± 7.5\tabcellsep 10.5 ± 0.5\\
\multicolumn{5}{l}{Values are expressed as Mean ± SD. *Body Mass Index (BMI)}\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_3}Table 4 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{6} \par 
\begin{longtable}{P{0.27999999999999997\textwidth}P{0.23666666666666666\textwidth}P{0.07333333333333333\textwidth}P{0.07833333333333334\textwidth}P{0.07833333333333334\textwidth}P{0.10333333333333333\textwidth}}
\tabcellsep Correlations\tabcellsep BMI\tabcellsep Spleen\tabcellsep Weight\tabcellsep Abdomen circumference\\
BMI\tabcellsep Pearson Correlation\tabcellsep 1.00\tabcellsep 0.54\tabcellsep 0.88\tabcellsep 0.84\\
\tabcellsep P-value\tabcellsep .\tabcellsep 0.000\tabcellsep 0.000\tabcellsep 0.000\\
Spleen\tabcellsep Pearson Correlation\tabcellsep 0.54\tabcellsep 1.00\tabcellsep 0.71\tabcellsep 0.55\\
\tabcellsep P-value\tabcellsep 0.000\tabcellsep .\tabcellsep 0.000\tabcellsep 0.000\\
Weight\tabcellsep Pearson Correlation\tabcellsep 0.88\tabcellsep 0.71\tabcellsep 1.00\tabcellsep 0.85\\
\tabcellsep P-value\tabcellsep 0.000\tabcellsep 0.000\tabcellsep .\tabcellsep 0.000\\
Abdomen circumference\tabcellsep Pearson Correlation\tabcellsep 0.84\tabcellsep 0.55\tabcellsep 0.85\tabcellsep 1.00\\
\tabcellsep P-value\tabcellsep 0.000\tabcellsep 0.000\tabcellsep 0.000\tabcellsep .\\
Height\tabcellsep Pearson Correlation\tabcellsep 0.43\tabcellsep 0.72\tabcellsep 0.79\tabcellsep 0.56\\
\tabcellsep P-value\tabcellsep 0.000\tabcellsep 0.000\tabcellsep 0.000\tabcellsep 0.000\\
\multicolumn{2}{l}{0.90 -1.00 very strong relationship.}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{0.70 -0.89 strong relationship.}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{0.50 -0.69 middle relationship.}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{0.00 -0.49 weak relationship}\tabcellsep \tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
  {\small\itshape [Note: © 2013 Global Journals Inc. (US) Global Journal of Medical Research 21 Volume XIII Issue II Version I]} 
\caption{\label{tab_4}Table 6 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{5} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_5}Table 5 :}\end{figure}
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