Knowledge, Attitudes and Practice Among Primary Care Physicians in Sudan Regarding Prediabetes: A Cross-Sectional Survey

Background:

Prediabetes is an important stage before diabetes that can be treated with intensive lifestyle changes. The aim of this study was to assess knowledge, attitudes, and practice of primary care physician in Sudan about prediabetes.

Methods:

A cross-sectional questionnaire-based study was conducted among primary care physicians working at two family and primary health care centers in Khartoum. Data were analyzed using descriptive statistics and expressed as percentages.

Results:

Out of 200 primary care physicians, 189 completed the questionnaire. 60.8% of the participants had satisfactory knowledge about prediabetes and positive attitude towards prediabetes and their practice was relatively good. Knowledge score was significantly correlated with age (P = 0.000), duration of experience (P value = 0.000), the number of working hours per day (P value = 0.001), and the number patients seen per day (P value = 0.001). Logistic regression analysis showed that attending courses relevant to prediabetes revealed statistically significant result in knowledge, and attending such courses were likely to be associated with gaining sufficient knowledge than those who didn’t by 2 times (P value 0.033, OR 2, CI. 1.063-4.079).

Conclusions:

Primary care physicians in Sudan have satisfactory knowledge, attitude, and practice about prediabetes. As they are in the front line in dealing with community, primary care physicians’ efforts can help in slowing down the epidemic of diabetes in Sudan.

Risk factors associated with lower extremity amputation in Sudanese individuals with diabetes: The need for improvement in primary health care system

Background:

Lower extremity amputation (LEA) in individuals with diabetes is a serious health issue with a considerable physical and social burden. The aim of this study was to assess the prevalence and risk factors associated with LEA in diabetic foot ulcer (DFU) patients.

Materials and Methods:

This was a cross-sectional health facility-based study that recruited 315 diabetes individuals with foot ulcers from the diabetes center in Khartoum, Sudan. Direct interviewing of subjects was used to obtain data, using a standardized validated questionnaire. Chi-square and logistic regression analysis were used in data analysis.

Results:

69.5% of the diabetic participants were aged 50 years old or more, and 71.1% were males. Most of the subjects (48.2%) were diabetics for a duration of >10 years, while more than one third (37.5%) of them were diabetic for 5–10 years. The majority (89.5%) had type 2 DM, while only 10.5% were type 1 DM. Two hundred forty-five patients had a left lower foot ulcer; 55.1% of the patients' ulcers were present in the toes, while 21.6% were in the foot sole. The overall prevalence of lower limb amputation was 17.1%. Individuals with diabetes patients with LEA had a higher incidence of hypertension (P = 0.000), retinopathy (P = 0.000), nephropathy (P = 0.002), ulcer size >2.5 cm (P = 0.000), and neuropathy (P = 0.000) through Chi-square analysis. Furthermore, logistic regression analysis showed that amputation was significantly associated with retinopathy (P = 0.000), size of ulcer (P = 0.000), and neuropathy (P = 0.016).

Conclusion:

The overall prevalence of LEA was 17.1%. The primary risks factors associated with amputation were presence of neuropathy and ulcer size >2.5 cm. Presence of retinopathy predispose diabetic individuals to amputation. Amputation is associated with disability and psychological problems; therefore, there is an urgent need for more improvement in preventative measures and primary health care system in low resource setting country like Sudan in order to decrease diabetes complications, especially patient's education about diabetes management by primary care physicians.

Impact of inter-hospital transfers on the prevalence of resistant pathogens in a hospital-community system

The spread of resistant bacteria in hospitals is an increasing problem worldwide. Transfers of patients, who may be colonized with resistant bacteria, are considered to be an important driver of promoting resistance. Even though transmission rates within a hospital are often low, readmissions of patients who were colonized during an earlier hospital stay lead to repeated introductions of resistant bacteria into hospitals. We developed a mathematical model that combines a deterministic model for within-hospital spread of pathogens, discharge to the community and readmission, with a hospital-community network simulation of patient transfers between hospitals. Model parameters used to create the hospital-community network are obtained from two health insurance datasets from Germany. For parameter values representing transmission of resistant Enterobacteriaceae, we compute estimates for the single admission reproduction numbers R_A and the basic reproduction numbers R₀ per hospital-community pair. We simulate the spread of colonization through the network of hospitals, and investigate how increasing connectedness of hospitals through the network influences the prevalence in the hospital-community pairs. We find that the prevalence in hospitals is determined by their R_A and R₀ values. Increasing transfer rates between network nodes tend to lower the overall prevalence in the network by diluting the high prevalence of hospitals with high R₀ to hospitals where persistent spread is not possible. We conclude that hospitals with high reproduction numbers represent a continuous source of risk for importing resistant pathogens for hospitals with otherwise low levels of transmission. Moreover, high risk hospital-community nodes act as reservoirs of pathogens in a densely connected network.

Assessment of lifestyle modifications among Sudanese individuals with diabetes: The situation so far and the need to do more

BACKGROUND

Inadequate lifestyle practices among individuals with diabetes may influence the progression of diabetes and its complications. The aim of this study was to assess the lifestyle practices among individuals with diabetes in Sudan.

METHODOLOGY

This was a descriptive, cross-sectional, health facility-based study conducted in 3 diabetes centers treating individuals with diabetes. The data were collected using a standardized pretested metabolic questionnaire about lifestyle and were analyzed by performing descriptive and inferential statistics through SPSS program version 23.

RESULTS

A total of 528 patients with diabetes answered the questionnaire. There were 52.1% of female participants and 72.9% of urban residents. 23.9% were obese, regular exercise was reported by 27.7%, and no exercise by 17%. There was a statistically significant association between lifestyle practices and gender (P < 0.001), age (P < 0.001), educational level (P = 0.002), marital status (P < 0.001), duration of diabetes (P < 0.001), hypertension (P < 0.001), high-density lipoprotein (P < 0.001), low-density lipoprotein (P < 0.001), and HbA1c level (P < 0.001). Logistic regression analysis showed male gender and education were significantly associated with lifestyle changes. Men were more likely to engage in favorable lifestyle practices than women (P < 0.001), while those with no formal education were less likely to engage in healthy lifestyle (P < 0.001).

CONCLUSIONS

Health authorities in Sudan will need to put more efforts into education for promoting self-awareness and good lifestyle practices in the population with diabetes.

Socioeconomic impacts of elimination of onchocerciasis in Abu-Hamed focus, northern Sudan: lessons after elimination

OBJECTIVES

Onchocerciasis is one of the most devastating neglected tropical diseases and it is mostly prevalent in Africa. The disease has important heavy social and economic burdens on the infected populations including low productivity, unemployment, social isolation, and stigma. A cross-sectional study was implemented using a well-established questionnaire to investigate the socio-economic impacts of Onchocerciasis elimination in Abu-Hamed, River Nile State, Sudan in 2015; 512 participants in ten affected communities were interviewed.

RESULTS

Our findings revealed that these communities are recovering from the social and economic burden of the diseases. Ninety percent of the research participants reported general satisfaction about elimination of the disease in their community, 48.3% of them attended secondary school or university. Only 0.6% reported unemployment. Also, 25.3% and 24.7% of the participants were workers and farmers respectively. Except about the vector biting and nuisance, the majority of the respondents (90%) had no complain related to the disease after the elimination. Also, 90.5% of the participants reported either stable or increase in their work performance during the last 12 months. About 93.8% of the respondents were engaged in normal daily life activities and involved in happy events like marriage and giving birth during the last 12 months.

The prevalence and risk factors of stroke among Sudanese individuals with diabetes: Cross-sectional survey

INTRODUCTION:

Diabetes complications in Sudan were increasing at an alarming rate. The aim of this study was to assess the prevalence of stroke among Sudanese individuals with diabetes.

METHODOLOGY:

This cross-sectional study recruited 283 individuals with diabetes from three diabetes centers in Sudan. Data were collected using a standardized pretested questionnaire, and data were analyzed using Chi-square and logistic regression analysis.

RESULTS:

The average age of participants was 51 (±12 standard deviation) and 35% were aged between 51 and 60 years. Females were 66.8%, and most of the participants (73.9%) were from urban areas and 66.1% received formal education between primary school and university. Body mass index (BMI) classification showed that 34.3% were obese, 31.8% overweight, and 30.4% normal BMI. Diabetes for 1-5 years were observed in 71.7% and for more than 10 years (12%). The majority, i.e., 94.3% had type 2 diabetes mellitus while only 5.7% had type 1. Only one-third of the participants were able to achieve glycosylated hemoglobin (HbA1c) target for diabetes control. The prevalence of cerebrovascular accident (CVA) was 2.5%, hypertension (HTN) was 20%, ischemic heart disease 3.2%, and neuropathy was 45.6%. Chi-square test showed significant association between HbA1c, serum creatinine, total cholesterol, triglyceride, low density lipoprotein, high density lipoprotein level, and the presence of CVA. Logistic regression analysis showed HbA1c, and the duration of diabetes are significantly associated with the presence of CVA (P = 0.010, 0.014).

CONCLUSION:

The prevalence of stroke among Sudanese individuals with diabetes was around 2.5%. The main risk factors were HbA1c, HTN, and duration of diabetes.

Knowledge and practice of diabetic foot care in Sudan: A cross sectional survey

BACKGROUND

Diabetes in Sudan is real health challenge for health authorities especially optimum glycemic control and complications in particular diabetic septic foot. This is study aimed to assess knowledge of individuals with diabetes about self-foot care.

METHODS

This is descriptive cross sectional, health facility-based study conducted in diabetes center in Khartoum, Sudan. The study recruited 150 individuals with diabetes. Data was collected using a standardized pretested questionnaire.

RESULTS

Among the participants 64.7% were females and 35.3% were males, 36% of the participants were between the age of 51-60 years old. Good glycemic control (HbA1c) were achieved by 41.3% only. The participants who had good knowledge about diabetic foot self-care were 46.7%, poor knowledge 29.3% and moderate knowledge 24%. Good self-practice toward diabetic foot self-care was reported by 42.6%, moderate by 36.7% and poor practice by 20.7%. The awareness and practices significantly correlated with an increase in ages (≥51 years), higher level of education, medium income, unemployment, longer duration of diabetes > 10years, family history, controlled diabetes mellitus and education about diabetes complications and diabetic foot care (P value < 0.05).

CONCLUSIONS

Only (46.7%) of participants address good awareness and practices about self-foot care. Accordingly, there is a great need to provide continuous health education to the patients about diabetic foot self-care and this knowledge-application gap must be narrowed down.

Ethnicity and diabetes complications in Sudanese population: The need for further genetic population testing

BACKGROUND

The aim of the present study was to assess whether there is an association between ethnicity and the high prevalence of diabetes complications in Sudan.

METHODS

This was cross-sectional hospital-based study with 316 individuals with diabetes conducted in Khartoum state, Sudan. A questionnaire was used to collect demographic information. In addition to measurements of blood pressure, lipid profile and HbA1c, weight and height measurement were also performed for calculation of body mass index.

RESULTS

The study included individuals recruited from 62 tribes across Sudan. The effect of ethnicity on diabetic septic foot (DSF) was not statistically significant across different tribes (X-squared = 2.6098, df = 4, p-value = 0.6251). The effect of ethnicity on Albuminuria was also not statistically significant across different tribes recruited for this study (X-squared = 4.3787, df = 4, p-value = 0.3572). The Northern group carried a significantly higher unadjusted risk for development of retinopathy (OR = 1.8471, p-value = 0.04603). The Southern group was significantly different from the others regarding the effect of ethnicity on neuropathy, compared to the 'West' group (OR = 0.1905, p-value = 0.0345). The unadjusted effect for the Southern group was also significant (OR = 0.2933, p-value = 0.0320).

CONCLUSION

There was no role of ethnicity in term of DSF and albuminuria complications. However, retinopathy likely to be seen in tribes originally from north of Sudan, while neuropathy is more likely to be found in tribes originally from the south of Sudan. Further focus genetic population testing is needed.

Novel therapies in lupus nephritis

Renal disease continues to cause major morbidity and some mortality for around 30-40% of patients with systemic lupus erythematosus (SLE). Although the combinations of prednisolone and azathioprine or prednisolone and cyclophosphamide have been beneficial to many patients with SLE, they are not always effective and have significant side effects. It is very encouraging that new immunosuppressive drugs such as mycophenolate mofetil and more targeted therapies e.g., anti-CD20 are coming rapidly to larger scale clinical trials. The treatment of lupus nephritis is set to change quite rapidly in the next decade. In this review we highlight the likely major therapeutic advances.

From local to global: a qualitative review of the multi-leveled impact of a multi-country health research capacity development partnership on maternal health in Sudan

Background

There is a substantial body of literature on the principles of good partnerships and the rationale for such partnerships in research capacity strengthening. This paper illustrates the long term effects of a multi-country (8 countries) global partnership for health systems research capacity development (Connecting health Research in Africa and Ireland Consortium - ChRAIC) in relation to its contribution to capacity strengthening, public advocacy and policy influence at different levels and its practical achievements in Sudan in addressing access to maternal health services.

Methods

The authors (all members of the global partnership) reflect on the project in one of its’ partner countries, Sudan, over its’ five year duration. This reflection is supported by specific project data collected over the period of the project (2008–2014). The data collected included: (i) 6 monthly and annual donor reports; (ii) a mid-term internal and end of project independent evaluation of the entire project, and; (ii) a Ph.D study conducted by a member of the Sudanese research team.

Results

The ChRAIC project in Sudan achieved the deliverables set out at the beginning of the project. These included a national knowledge synthesis report on Sudan’s health system; identification of country level health systems research priorities; research capacity assessment and skills training, and; the training and graduation of a Sudanese team member with a Ph.D. Mechanisms established in Sudan to facilitate these achievements included the adoption of culturally sensitive and locally specific research and capacity strengthening methods at district level; the signing of a Memorandum of Understanding at country level between the Ministry of Health, research and academic institutions in Sudan, and; the establishment of country level initiatives and a research unit. The latter being recognized globally through awards and membership in global health forums.

Conclusion

We surmise that the ‘network of action’ approach adopted to partnership formation facilitated the benefits gained, but that adopting such an approach is not sufficient. More local and contextual factors influenced the extent of the benefits and the sustainability of the network.

Genetic diversity of lactase persistence in East African populations

Background

The expression of lactase which digests lactose from milk in humans is generally lost after weaning, but selected mutations influencing the promoter of the lactase gene have spread into the human populations. This is considered a classical example of gene-culture co-evolution, and several studies suggested that the lactase gene has been under strong directional evolutionary selective pressure in the past 5000 to 10,000 years.

Results

In the present study we investigated the distribution of three gene variants leading to lactase persistence in 12 different East African populations as well as one European population. Our results show that with the exception of Copts and Nilotic populations who are fully lactose non-persistent, the majority of populations of East Africa show at least partly lactose persistence, with both ethnic and socio-economic aspects playing an important role in the distribution of genetic variants. In this study, the variants C/G-13907 and T/G-13915, which are the major variants among the nomadic Arabs in the Arabia and Beja of East Africa, showed remarkable frequencies in Sudanese populations, especially those of pastoralists, in line with the historical links and bidirectional migration of nomadic populations between Arabia and East Africa. The C/T-13910 variant, generally associated with European populations is uniquely present among the Fulani.

Conclusions

These data indicate that a combination of socio-economic, ethnic and evolutionary factors converged to shape the genetic structure of lactase persistence in East African populations.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1833-1) contains supplementary material, which is available to authorized users.

The genetics of East African populations: a Nilo-Saharan component in the African genetic landscape

East Africa is a strategic region to study human genetic diversity due to the presence of ethnically, linguistically, and geographically diverse populations. Here, we provide new insight into the genetic history of populations living in the Sudanese region of East Africa by analysing nine ethnic groups belonging to three African linguistic families: Niger-Kordofanian, Nilo-Saharan and Afro-Asiatic. A total of 500 individuals were genotyped for 200,000 single-nucleotide polymorphisms. Principal component analysis, clustering analysis using ADMIXTURE, F_ST statistics, and the three-population test were used to investigate the underlying genetic structure and ancestry of the different ethno-linguistic groups. Our analyses revealed a genetic component for Sudanese Nilo-Saharan speaking groups (Darfurians and part of Nuba populations) related to Nilotes of South Sudan, but not to other Sudanese populations or other sub-Saharan populations. Populations inhabiting the North of the region showed close genetic affinities with North Africa, with a component that could be remnant of North Africans before the migrations of Arabs from Arabia. In addition, we found very low genetic distances between populations in genes important for anti-malarial and anti-bacterial host defence, suggesting similar selective pressures on these genes and stressing the importance of considering functional pathways to understand the evolutionary history of populations.

Outcome and impact of Master of Public Health programs across six countries: education for change

BACKGROUND

The human resources for health crisis has highlighted the need for high-level public health education to add specific capacities to the workforce. Recently, it was questioned whether Master of Public Health (MPH) training prepared graduates with competencies relevant to low- and middle-income countries (LMICs). This study aims to examine the influence of the MPH programs geared towards LMICs offered in Vietnam, China, South Africa, Mexico, Sudan, and the Netherlands on graduates' careers, application of acquired competencies, performance at the workplace, and their professional contribution to society.

METHODS

A self-administered questionnaire was sent to graduates from six MPH programs. Frequency distributions of the answers were calculated, and a bivariate analysis and logistic regression of certain variables was performed.

RESULTS

The response rate was 37.5%. Graduates reported change in leadership (69%), in technical position (69%), acquiring new responsibilities (80%), and increased remuneration (63%); they asserted that MPH programs contributed significantly to this. Graduates' attribution of their application of 7 key competencies 'substantially to the MPH program' ranged from 33% to 48%. Of the 26 impact variables, graduates attributed the effect they had on their workplace substantially to the MPH program; the highest rated variable ranged from 31% to 73% and the lowest ranged from 9% to 43%. Of the 10 impact variables on society, graduates attributed the effect they had on society substantially to the MPH program; for the highest rated variable (13% to 71%); for the lowest rated variable (4% to 42%). Candidates' attribution of their application of acquired competencies as well as their impact at the workplace varied significantly according to institution of study and educational background.

CONCLUSIONS

This study concludes that these MPH programs contribute to improving graduates' careers and to building leadership in public health. The MPH programs contribute to graduates' application of competencies. MPH programs contribute substantially towards impact variables on the workplace, such as development of research proposals and reporting on population health needs, and less substantially to their impact on society, such as contributing equitable access to quality services. Differences reported between MPH programs merit further study. The results can be used for curriculum reform.

Validation of public health competencies and impact variables for low- and middle-income countries

BACKGROUND

The number of Master of Public Health (MPH) programmes in low- and middle-income countries (LMICs) is increasing, but questions have been raised regarding the relevance of their outcomes and impacts on context. Although processes for validating public health competencies have taken place in recent years in many high-income countries, validation in LMICs is needed. Furthermore, impact variables of MPH programmes in the workplace and in society have not been developed.

METHOD

A set of public health competencies and impact variables in the workplace and in society was designed using the competencies and learning objectives of six participating institutions offering MPH programmes in or for LMICs, and the set of competencies of the Council on Linkages Between Academia and Public Health Practice as a reference. The resulting competencies and impact variables differ from those of the Council on Linkages in scope and emphasis on social determinants of health, context specificity and intersectoral competencies. A modified Delphi method was used in this study to validate the public health competencies and impact variables; experts and MPH alumni from China, Vietnam, South Africa, Sudan, Mexico and the Netherlands reviewed them and made recommendations.

RESULTS

The competencies and variables were validated across two Delphi rounds, first with public health experts (N = 31) from the six countries, then with MPH alumni (N = 30). After the first expert round, competencies and impact variables were refined based on the quantitative results and qualitative comments. Both rounds showed high consensus, more so for the competencies than the impact variables. The response rate was 100%.

CONCLUSION

This is the first time that public health competencies have been validated in LMICs across continents. It is also the first time that impact variables of MPH programmes have been proposed and validated in LMICs across continents. The high degree of consensus between experts and alumni suggests that these public health competencies and impact variables can be used to design and evaluate MPH programmes, as well as for individual and team assessment and continuous professional development in LMICs.

A Pilot Study Evaluating the Stigma and Public Perception about the Causes of Depression and Schizophrenia

BACKGROUND

To evaluate public perceptions towards the causes of depression and schizophrenia and identifications of factors resulting stigma towards mental ill.

METHOD

A cross-sectional study was conducted among the inhabitants of Pulau-Pinang, Malaysia in March, 2009. A 24-item questionnaire was used to obtain respondent views. A non-probability (i.e convenient sampling method) was used to approach the potential respondents. Data analysis was conducted using SPSS version 13 ®, non-parametric statistics (Chi-square) was applied to determine the association. Alpha value less than 0.05 were considered significant.

RESULTS

One hundred respondents showed their willingness to participate in the study; overall response of the study was 40.0%. Majority 69% of the respondents were Malays, followed by Chinese and Indians. Public recognition toward depression was higher than schizophrenia. Lack of social support (X(2)= 4.832, P= 0.049), chemical imbalance in Brian (X(2)=6.132, P= 0.013*) and believes in supernatural factors (X(2)= 6.700, P= 0.050) were the commonly shared reasons for the mental disorders. Evaluation in terms of stigma revealed that majority 61 (55.0%). Individuals with mental disorders were not friendly (X(2)= 1.008, P= 0.050). Furthermore, one third of the population believe that they are moody, dangerous and unpredictable, it is better to avoid them.

CONCLUSION

Overall findings revealed that Malaysians believe in supernatural reasons for the prevalence of mental disorders. Similarly the level of stigma towards mentally ill was higher among the respondents.

A comparison of autoimmune liver disease in juvenile and adult populations with systemic lupus erythematosus-a retrospective review of cases

OBJECTIVE

To compare the prevalence and type of autoimmune liver disease in adult and juvenile patients with systemic lupus erythematosus (SLE) in a large UK cohort.

METHODS

A retrospective analysis was performed of patients attending the adult and juvenile lupus clinics at University College Hospital and Great Ormond Street Hospital, respectively, between January 1978 and December 2004. Patients with autoimmune liver disease were identified by searching an existing database (adults) and by case note review (juveniles). Histological diagnosis and autoantibody profile was noted and the time that had elapsed in months between the two diagnoses calculated.

RESULTS

Of 377 adult patients and 92 juvenile patients, 5 and 9 respectively, had histologically confirmed autoimmune liver disease. This corresponds to a statistically significant (P < 0.001) greater prevalence in juvenile onset patients of 9.8% compared with 1.3% in adult patients. The juvenile patients were all positive for smooth muscle antibody and had histological changes consistent with autoimmune hepatitis. The adult patients had a variable antibody profile and one patient had histological changes consistent with primary biliary cirrhosis. In all of the juvenile patients, but notably in none of the adult patients, the liver disease predated the diagnosis of SLE (P < 0.001).

CONCLUSIONS

Our study confirms that autoimmune liver disease occurs infrequently in adult lupus patients but should be considered in a patient with persistent liver enzyme abnormalities. However, in our study there is a significantly higher prevalence in juvenile lupus patients. This association is previously unreported.

Successful medical treatment of acute bilateral emphysematous pyelonephritis

Emphysematous pyelonephritis most often presents as an acute medical emergency, typically in a septic diabetic patient with acute renal failure. The management of this condition has traditionally been surgical, with nephrectomy. However, some recent reports have described successful medical interventions. We describe a case of acute bilateral emphysematous pyelonephritis in a frail patient not suitable for bilateral nephrectomy and long-term dialysis. This condition was managed medically, not surgically, with intensive antibiotic and circulatory support. The outcome was complete recovery after months of hospital-based treatment. We discuss the management of this rare but important condition in detail.

Pulmonary hypertension, cardiac disease and pregnancy

OBJECTIVE

To ascertain the significance of coexisting pulmonary hypertension in cardiac disease in pregnancy.

METHODS

Over a 3-year period a group of pregnant women with cardiac disease was followed until 6 weeks postpartum. Twenty women with pulmonary hypertension were compared with 20 controls without pulmonary hypertension with particular reference to maternal and fetal outcome. Analysis of data was carried out using Fisher's exact test and Student's t-test.

RESULTS

Except for Eisenmenger's syndrome, there were no differences in maternal morbidity and mortality between the two groups. There were more low birth weight babies but no significant differences in premature delivery rate, mode of delivery or perinatal mortality.

CONCLUSION

Except for Eisenmenger's syndrome, coexisting pulmonary hypertension complicating cardiac disease in pregnancy generally has a favorable outcome for both mother and fetus.

Bilateral pure gonadoblastoma in a 46 XY individual--a case report

We report here a rare case of bilateral pure gonadoblastoma which accounts for only 0.2% of all ovarian tumours seen at Universiti Kebangsaan Malaysia from 1980 to 1987. This tumour occurred in an 18 year old Chinese "female" who presented with primary amenorrhoea. Examination showed a phenotypic female with poorly developed external gentalia. Exploratory laparotomy revealed a hypoplastic uterus, rudimentary fallopian tubes and streak gonads. Histological examination of the gonads showed a mixed tumour comprising large germ cells and smaller sex cord derivatives arranged in characteristic nests or islands containing hyaline material.