Experience with renal cell carcinoma- a single centre study from Khyber Pakhtunkhwa

Objective: To analyze the clinical characteristics, management and outcome of renal cell carcinoma [RCC] and its variants in patients treated at CMH Peshawar, from Aug 2011 to Aug 2014

Study Design: Retrospective descriptive

Place and Duration of Study: Combined Military Hospital [CMH] Peshawar, from Aug 2011 to Aug 2014

Material and Methods: All patients who underwent nephrectomy for renal masses at our institution between Aug 2011 and Aug 2014 were included in the study. The demographic distribution, symptoms, tumour characteristics, operative findings and histopathology reports were extracted from the hospital records and analysed via SPSS version 20.0

Results: Among 27 patients male to female ratio was 1.25:1. Mean age was 55.5 +/- 11.7 years. Flank pain was the commonest symptom reported. Mean maximum diameter of the tumour was 13.6 +/- 4.6 cm. All the tumours were malignant and most common histopathological type was conventional/clear cell RCC. All patients were treated by radical nephrectomy through transperitoneal approach. One patient developed post operative thrombosis of inferior vena cava. Two patients developed metastatic deposit during follow up

Conclusion: Renal tumours in the study population of Khyber Pakhtunkhwa at our centre presented late with large sizes, and incidental diagnosis is rare. Health education and availability of advanced diagnostic facilities will improve outcomes

Comparison of the learning of two notations: a pilot study

Introduction: MICAP is a new notation in which the teeth are indicated by letters [I-incisor, C-canine, P-premolar, M-molar] and numbers [1,2,3] which are written superscript and subscript on the relevant letters. FDI tooth notation is a two digit system where one digit shows quadrant and the second one shows the tooth of the quadrant. This study aimed to compare the short term retention of knowledge of two notation systems [FDI two digit system and MICAP notation] by lecture method

Methods: Undergraduate students [N=80] of three schools participated in a cross-over study. Two theory-driven classroom based lectures on MICAP notation and FDI notation were delivered separately. Data were collected using eight randomly selected permanent teeth to be written in MICAP format and FDI format at pretest [before the lecture], post-test I [immediately after lecture] and post-test II [one week after the lecture]. Analysis was done by SPSS version 20.0 using repeated measures ANCOVA and independent t-test

Results: The results of pre-test and post-test I were similar for FDI education. Similar results were found between post-test I and post-test II for MICAP and FDI notations

Conclusion: The study findings indicated that the two notations [FDI and MICAP] were equally mind cognitive. However, the sample size used in this study may not reflect the global scenario. Therefore, we suggest more studies to be performed for prospective adaptation of MICAP in dental curriculum

Comparison of mean operative time in patients undergoing Ho:YAG laser lithotripsy and pneumatic lithotripsy in ureterorenoscopy for ureteric calculus

Objectives: To compare the mean operative time in patients undergoing Ho:YAG laser lithotripsy and pneumatic lithotripsy for ureteric stones

Study Design: Cross-sectional study

Place and Duration of Study: This study was conducted at the Armed Forces Institute of Urology, Rawalpindi from August 2015 to 12 February 2016

Materials and Methods: The study included 60 patients requiring ureteroscopic lithotripsy for treatment of ureteric calculi. Patients were divided into Ho:YAG lithotripsy group [30] and pneumatic lithotripsy group [30]. The operative time in minutes was calculated in all patients from initial cystoscopy till ending of ureteroscopy after the stone fragmentation into small particles. All the information was recorded on a specially designed questionnaire

Results: The mean age and SD of all patients was 36.90 +/- 12.11. The male to female ratio was 49:11. The baseline demographic variables; mean age, gender, side of stone and location of stone were found similar between the two groups [p>0.05]. The type of intra-ureteral lithotripsy was found a significant predictor of mean operative time taken for the procedure. The average operative time taken for Pneumatic lithotripsy procedure increased by 9.13 minutes as compared to the Ho: YAG laser lithotripsy procedure [R[2]=0.33, p<0.001]. The mean operative time was not found significantly different between males and females; age groups; sides of stones and different locations of stones, as a whole, as well as in both groups separately [p>0.05]

Conclusion: It is speculated that the Ho:YAG laser lithotripsy is a better procedure compared to the Pneumatic lithotripsy, in terms of the operative time required for the procedure

Efficacy of tranexemic acid in preventing alveolar osteitis after third molar extraction

Objective: to determine the efficacy of tranexemic acid in preventing alveolar osteitis after third molar extraction

Study Design: randomized control trial

Place and Duration of Study: June 2013 to June 2014. Oral and Maxillofacial Surgery department, Dental section, Punjab Medical College, Faisalabad

Materials and Methods: thirty patients, between the ages 18-35 years without any gender discrimination, presenting for removal of bilateral mandibular impacted third molars were included in the study. One side was the study group [Group A] and the other side acted as control [Group B]. Group A was given Inj Transamine 500mg IV 10 minutes before surgical removal however no pre-operative medication was given to group B. The rest of the procedure was carried out in a standard fashion in both the groups. The frequency of dry socket was assessed in both the groups and compared using Chi Square test

Results: the age ranged from 18-35 years with a mean age of 23.3+/-3.5 years. Out of these 30 patients 18 were males and 12 females with an overall M:F ratio of 1.5:1. Eight patients out of the 18 males were smokers and 3 females out of 12 were using oral contraceptives. Two patient [6.7%] developed dry socket in Group A, and 4 [13.3%] developed dry socket in Group B. Although the control group showed a greater frequency of dry socket but overall the results were statistically insignificant [P-value>0.05]

Conclusion: although IV tranexemic acid cannot prevent dry socket completely however it can decrease the incidence of dry socket formation and its use may be considered in patients who show an increased predisposition towards formation of dry socket

Neonatal seizures; types, etiology and long term neurodevelopmental outcome at a tertiary care hospital

To study the types, etiology and long term neurodevelopmental outcome in neonates with seizures.A descriptive cross-sectional study. PNS Shifa Naval hospital Karachi from Jan 2011 to Feb 2014.Population: Ninety six neonates of either gender presented with seizures at NICU PNS Shifa Naval hospital Karachi were studied. Method: All neonates with seizures were evaluated. The seizures were classified according to the simiology. They were investigated according to NICU protocol to confirm the underlying diagnosis and timely management. The patients after discharge were regularly followed up for one year to assess the long term neurodevelopmental outcome. A total of 96 neonates with seizures were studied and it was observed that 60 [62.5%] were male babies and 56 [58.33%] were term with a male to female ratio of 1.6:1. Majority of the neonatal seizures were seen in 1stweek of life [85%]. The most common type of seizures was clonic 40 [41.67%] followed by subtle 20 [20.84%], mixed 16 [16.67%], tonic 10 [10.41%], myoclonic 5 [5.20%] and unclassified 5 [5.20%]. Antiepileptics were used in 82 [85.41%] patients. Phenobarbitone 49 [59.76%] was most commonly prescribed drug. The most common cause of seizures was birth asphyxia 48 [50%] followed by metabolic 16 [16.68%], sepsis 10 [10.41%], intracranial hemorrhage 6 [6.25%], bilirubin encephalopathy 4 [4.16%], inborn errors of metabolism 2 [2.08%], birth trauma 2 [2.08%] and unknown etiology 5 [5.20%]. 25 [26.04%] patients develop adverse neurodevelopmental outcome i.e. cerebral palsy with epilepsy 10 [40%] and cerebral palsy without epilepsy 05 [20%], developmental delay 10 [40%]. Mortality in the study was 12 [12.5%]. Clonic seizures are commonest in neonates apart from infants and children who have GTCS. The most common etiology of seizures in neonates is birth asphyxia. Phenobarbitone is still the most commonly prescribed antiepileptic. Quick assessment, timely diagnosis and aggressive management according to the etiology are necessary to prevent the morbidity and mortality associated with neonatal seizures. Long term neurodevelopmental outcome is worse in patients with birth asphyxia especially with low Apgar score at 5 minutes. Normal delivery and birth asphyxia were the major risk factors for cerebral palsy

Dengue fever; a clinical experience

Dengue is the most prevalent mosquito-born viral illness in the world. Clinically dengue ranges from asymptomatic, non-febrile illness, classic dengue to dengue hemorrhagic fever/dengue shock syndrome. This study was included 79 patients conducted at Nawaz Sharif Social Sevurity Hospital, Lahore during the epidemic of dengue in Lahore from September 2011 to Dec 2011. Twenty out of 79 patients suspected of dengue fever were dengue IgM positive. Male to female ratio was 1.19: 1. Our study included 79 patients suspected of having dengue fever. Fever was the most common symptom in these patients. Early identification of dengue with risk of developing hemorrhage is an important clinical objective. The morbidity and mortality can be reduced by appropriate and judicious treatment of dengue patients

Biliary bypass surgery - Analysis of indications and outcome of different procedures

This study reports the indications and outcome of various biliary bypass surgical procedures from a single centre over a period of 10 years. This is a prospective observational study conducted over a period of 10 years [January 2001-december 2010]. A total of 1500 patients were included, who underwent pancreatico-biliary surgery due to common bile duct [CBD] stones, congenital anomalies of biliary tree, unoperable pancreatico-biliary malignancies, CBD strictures and cases who developed iatrogenic biliary injuries during cholecystectomy [both open and laproscopic] during this period of time. The patients who required biliary bypass surgery were further analysed for indications and outcome. Out of 1500 patients 83 [5.53%] required biliary bypass surgical procedures. The CBD stones were observed as the most common indication [25.3%], followed by CBD injuries after open [10.84%] or laproscopic-cholecystectomy [14.46%], carcinoma head of pancreas [12.05%] and CBD obstruction [14.46%] either due to CBD strictures or unknown distal obstruction. Roux-en-Y-hepatico-jejunostomy [26.51%] was the most frequently performed procedure, followed by choledochoduodenostomy and Roux-en-Y choledocho-jejunostomy [i.e. 25.3% and 12.05% respectively]. Roux-en-Y biliary bypass procedure was observed to be associated with better outcome in terms of rate of complications as well duration of hospital stay. Biliary bypass surgical procedures are the better options to restore the continuity of biliary system in patients with iatrogenic biliary tree injuries and un-operable pancreatico-biliary malignancy. Roux-en-Y biliary bypass procedure is safe and problem solving method in these cases

Diagnostic laparoscopic findings in chronic pelvic pain

To assess the cause of pain on diagnostic laparoscopy in women with chronic pelvic pain and equivocal clinical and ultrasound examination. Cross-sectional observational study. Red Crescent General Hospital, Hyderabad, Sindh, from January 2007 to December 2009. All the women presenting with chronic pelvic pain for more than 6 months duration, without any obvious pathological findings on clinical as well as on ultrasound examination were recruited. Women with chronic pelvic pain and having pelvic pathological lesions detected on clinical and/or ultrasound examination were excluded. Clinical, ultrasound, and laparoscopic data was collected and analyzed on SPSS version 14. The results were described as frequency, proportion, compared by chi-square test with significance at p < 0.05. Highest frequency of chronic pelvic pain was observed in women aged between 26 - 35 years [62.4%], 53 out of 85 women. Most of these women were married [90.6%] and nulliparous [47.1%]. Pain was reported as dull and sharp by 35 women [41.2%], infertility [n = 46, 54.1%] and dyspareunia [n = 45, 52.9%] were the commonest co-existent complaints. On laparoscopic examination, pathological lesions were detected in 65, tuberculosis in 17 [20%] endometriosis in 11 women [12.9%], pelvic inflammatory diseases and pelvic adhesion in 8 [9.4%] women each and ovarian cyst in 6 women [7.1%]. Positive laparoscopic yield was high in women with pelvic pain. Pelvic tuberculosis was the most common pathology detected followed by endometriosis, pelvic inflammatory disease and adhesions

Inverted papilloma of ureter: a rare cause of hydronephrosis

A case of hydronephrosis with a rare underlying cause in a 35 years old male is described. He reported with pain in the left lumbar region with a past history of left ureterolithotomy. The ultrasound and IVU studies were suggestive of left hydronephroureter. CT Scan showed left hydronephroureter with narrowing at the lower end of left ureter. Ureterorenoscopy [URS] confirmed polypoidal lesions in the left lower ureter, completely obliterating the lumen and involving the whole circumferential wall of the lower ureter. The biopsy of the lesion revealed an inflammatory polyp. Accordingly open surgical intervention was planned. Excision of the lower third of left ureter with ureteric reimplantation was done with a Boari flap. The histopathology report of the lower third of ureter confirmed inverted papilloma of ureter. The patient made a smooth postoperative recovery

Pattern of malignant renal tumours using 2004 who classification of renal tumours on radical nephrectomy

Objective: To determine the type of malignant renal tumours subjected to radical nephrectomy at a tertiary care urology unit using the 2004 WHO classification for renal tumours. Methods: It was an observational study conducted at Department of Urology, AFIU Rawalpindi, from October 2008 to September 2010. The study included 92 patients with malignant renal tumours of both genders aged above 15 years. The histopathological types and grades were recorded along with the gross tumour presentation. The data was entered in structured proforma and analysed for descriptive statistics using SPSS-14. Results: Over the span of 24 months study, 92 cases of malignant renal tumours were subjected to radical nephrectomy. The age was 16–82 [57.23 +/- 14.61] Years and male to female ratio was 2.1:1. The lesions were mostly unifocal [96.7%] and 58.6% affecting the right side. The commonest malignant renal tumour encountered was the conventional clear cell renal carcinoma [78.2%]. The other tumours in descending order were the transitional cell carcinoma [7.6%], papillary [chromphilic] renal cell carcinoma [6.5%], renal cell carcinoma unclassified [3.2%], chromophobe renal cell carcinoma [2.1%], Wilm's tumour and oncocytoma [1.7%]. T1 lesions were found in 42 cases [45.6%], T2 lesions in 25 cases [27.1%], T3a lesions in 17 cases [18.4%] each, while 8 cases [8.6%] had T3b lesions. Four cases had high and 3 had low grade lesions in transitional cell carcinoma. Wilm's tumour had favourable prognosis, 1 case had oncocytoma limited to kidney. Among the rest, 26 [28.2%] were G1, 35 [38%] were G2, 16 [17.3%] were G3, and 6 [6.5] were G4. Conclusion: The commonest type of the malignant renal neoplasm remains the clear cell [conventional] renal cell carcinoma. The lesions from T1 to T3 are amenable to radical nephrectomy and may not include the ipsilateral adrenalectomy as well. The grade may range from G1 to G4

Comparative study of conventional open versus laparoscopic cholecystectomy for symptomatic cholelithiasis

To compare the results of conventional open with laparoscopic cholecystectomy regarding their operative time and postoperative parameters. This is a comparative study of 400 patients of cholelithiasis operated for either open or Laparoscopic cholecystectomy during five years from January 2004 to December 2008. The cases were compared for operative time and various postoperative parameters in order to assess the advantages and disadvantages of each procedure. The patients were divided into two groups; group OC for open and group LC for laparoscopic cholecystectomy, each comprising of 200 cases. The operative time was longer in OC than LC patients with mean operative time of 54.16 +/- 11.94 minutes in OC and 46.89 +/- 14.83 minutes in LC group [P<0.001]. The overall frequency of postoperative complications was relatively high in OC group 50.5% as compared to LC [37%] including all minor and major problems with combined morbidity of 43.75% [P<0.001]. The mean hospital stay was shorter in LC group as compared to OC group i.e. 3.02 +/- 1.75 [range 1-5] days versus 5.56 +/- 9.8 [range 4-10] days respectively. Return to normal work was also significantly shorter in LC group i.e. 18.06 +/- 5.16days [range 1-4 weeks] as compared to 31.61 +/- 7.6 days [range 3-6 weeks] in OC group with p value <0.001. The laparoscopic cholecystectomy is superior to open cholecystectomy due to short operative time, early mobilization and fast recovery, less postoperative pain and complications, short hospital stay and early return to work

Factors responsible for prolonged postoperative hospital stay after laparoscopic cholecystectomy

To identify various factors which prolong post-operative hospital stay after laparoscopic cholecystectomy. This is an observational prospective study conducted at a teaching hospital over a period of five years [Jan 2005-Dec 2010] and includes 580 patients of symptomatic cholelithiasis, admitted and treated by laparoscopic surgery. All patients were observed from 1st postoperative day to date of discharge and different operative, postoperative and patient related variables were recorded on a proforma which were found responsible for an unduly prolonged post-operative stay in the hospital. The duration decided for short stay was 48 hours and duration more than that was considered as prolonged stay. Out of 580 patients, 187 [32.24%] had prolonged stay extending from 3-28 days. Majority of patients presented in 4[th] and 5[th] decade [60.52%] with pain in right hypochondrium [58.79%] and pain in right hypochondrium combined with pain in epigastrium [27.6%] as main clinical features. Twenty eight variables were identified comprising of 10 patients related [15.86%], 12 surgery related [16.55%] and 6 post-surgery related [16.38%] which contributed to prolong the hospital stay. Patients having co morbid conditions, difficult operative procedure and major postoperative complications were main factors for prolonged stay. The prolonged post-operative hospital stay can be reduced by careful pre-operative assessment, meticulous surgery and proper post-operative management

Complications of pre-term infants in the neonatal unit

To assess the complications of preterm infants in neonatal intensive care unit and compare that with those faced by preterm infants in western neonatal intensive care unit. A prospective comparative study. This study was conducted at Paediatrics Department, Shaikh Zayed Hospital Lahorefrom 1[st] December 1997 to 30[th] November 1998. All neonates delivered before 37 weeks and admitted to the neonatal Intensive care unit [NICU, SZH] were included in the study. It was a prospective study conducted over a period of one year from 1[st] December 1997 to 30[th] November 1998. The study population included 170 preterm neonates. For the purpose of study, these infants were divided into three gestational age groups i.e. < 30 weeks gestational age, 30 to 35 weeks gestational age, and > 35 weeks gestational age. These neonates were then prospectively followed till discharge from NICU. Out of the 170 preterm infants admitted to NICU, 128 infants survived and were discharged under stable conditions, while 42 infants expired. Maximum number of complications and highest mortality i.e. 87% was seen among the most premature group, i.e. below 30 weeks gestational age. Mortality in the gestational age group 30 to 35 weeks was 43%, while it was 9% in the gestational group >35 weeks

Bladder outlet obstruction in a 5 years boy

We report a 5 years old boy with bladder outlet obstruction secondary to a fibroepithelial polyp of prostatic urethra. The micturating cystourethrogram showed a filling defect in the posterior urethra. Cystourethroscopy revealed a polyp in the prostatic urethra proximal to the verumontanum. Transurethral resection was done and histopathology confirmed fibroepithelial polyp of the urethra

rare complication of forgotten ureteral stent

A 35 years old lady presented with history of something coming out of the genitalia for the last 5 days. She also had history of pain in the left lumbar region which was initially investigated but the patient did not follow-up. About 15 years ago she also underwent left ureteric reimplantation. On examination, a stick like tube was protruding out of the urethral meatus which was fixed to the underlying vesical calculus. The calculus was evident radiologically and on ultrasound. The projecting portion of the stick like tube was cut and the vesical calculus with the inner portion of the tube was removed by open procedure. On evaluation of the specimen, it was found that the vesical calculus was fixed to the plastic tube which had concretions around it. This plastic tube had been placed after the ureteric reimplantation done 15 years age and the patients was not aware of it

Transobturator tension free vaginal tapes; a simple, effective and economical treatment for genuine stress incontinence in females

Objective of this study was to assess the effectiveness of Transobturator tension free vaginal tape [TOT] for the treatment of the genuine stress incontinence by using improvised instruments i.e. specific needles, which is far economical than the patent company made TOT set. Prospective cohort study Place and Duration of Study: This study was carried out in Armed Forces Institute of Urology [AFIU] Rawalpindi from Jan 2007 to Jun 2009 Thirty eight patients were included in study and were operated upon in two and half years. Polypropylene mesh was used transvaginally as mid urethral sling through the obturator foramen 'outside in' technique using special needles. All the patients who only had genuine stress incontinence. Were included. Results:: A total of 31 [81.57%] of the patients had total satisfaction post operatively. Four [10.52%] patients had equivocal results but improved and had incontinence only when there was strenuous and tough strain. Only 1 [2.63%] patient had no effects on the disease. Two [5.26%] patient had retention of the urine postoperatively for which Foley catheter had to pass for maximum of 18 days. Three [7.89%] patients had minor infection at exit sites of wound and were treated with the oral antibiotics. Genuine stress incontinence [GSI] is quite common problem in our females especially who had multiple deliveries .TOT is simple, effective and very economical solution to have the best results in our setup. Patients selection, detailed history physical and pelvic examination are most important factors to have the required results

Dual thyroid ectopy in an old woman

Very few cases with dual thyroid ectopy and a normally located thyroid gland have been reported. A 65 years old woman presented with hemoptysis and mild dysphagia 5 years after thyroidectomy. On direct laryngoscopy a supraglotic mass was detected and removed; which on histopathology turned to be an ectopic thyroid tissue. On barium swallow lateral view of the neck demonstrated a mass between trachea and esophagus at C4-6 level. CT scan confirmed a high attenuation, mass posterior to trachea in sub-cricoid area. Suspecting another ectopic thyroid here, Technetium-99 scans were done, while on thyroxine and 4 weeks without it: earlier was inconclusive but the later confirmed another ectopic thyroid in thyroid bed on left side with a tail on right. The diagnosis was dual ectopic thyroid tissue in supraglottic area and the thyroid area [laterally and to the left] extending between trachea and esophagus at C4-6 level producing difficulty in breathing and mild dysphagia. This was a case of dual ectopic thyroid. It emphasizes that thyroid scan should be routinely performed in all thyroid cases and all the suspicious areas studied

Obturator nerve block; transurethral resection of lateral bladder wall tumours [TUR-BT]

To evaluate the efficacy of obturator nerve block combined with spinal anaesthesia for prevention of adductor muscle spasm and its associated complications during transurethral resection of bladder tumours located at its lateral and inferolateral wall. A prospective study. At AFIU Rawalpindi. From January 2005 to December 2006. Material and method Fifty patients who had tumours at their lateral / inferolateral bladder wall of physical status ASA I - IV received spinal anaesthesia at 3rd or 4th lumbar space followed by obturator nerve block with a view to preventing adductor jerk during resection of tumour. There was complete suppression of adductor jerk in 45 [90%] patients and surgery was completed smoothly. Two patients [4%] had mild adductor jerk and additional sedation was required. The block failed to work in 3 [6%] cases and required conversion to general anaesthesia. Thus the procedure was successful in 94% [complete and partial suppression of jerk. We conclude that spinal anaesthesia combined with obturator nerve block is an effective technique for preventing adductor jerk during TUR-BT, thus avoiding intra-operative and post operative complication

Efficacy of pneumatic Lithoclast in the management of ureteric calculi

Background: To assess the efficacy and safety of pneumatic lithoclast in the management of ureteric calculi

Methods: One hundred and four patients with ureteric calculi were treated by pneumatic lithoclast at department of Urology Services Hospital Lahore from Jan 2005 to December 2006. Record of the patients was analyzed retrospectively. Patients above 15 years from both sexes with calculi measuring more than 0.5cm [in the largest diameter] were treated in upper, middle, and lower ureter. Calculi were approached with 8fr ureteroscope and fragmented with Swiss lithoclast. After the completion of the procedure, ureter was stented. Patients were followed up till they became stone free. Following parameters were assessed: stone size, site, laterallity, degree of fragmentation, success rate, stone migration, type and duration of stenting, post operative hospital stay and complications. Requirement of another procedure or inability to enter the ureter were considered failure

Results: One hundred and six ureteric calculi were treated in 104 patients. Amongst those, 22 stones were in upper ureter, 16 in the middle ureter and 68 stones were in lower ureter. Mean stone size was 11.2mm [largest diameter]. Overall success rate was 89.2%. Whereas success rate in upper, middle and lower ureter was 63.6 %, 87.5% and 95.6% respectively. Mean postoperative hospital stay was 26.5 hours. There were no major complications

Conclusions: Pneumatic lithoclast with URS is effective and safe in the management of the ureteric calculi. However, success is limited in the upper ureter

Expressed emotions and schizophrenia in Pakistan

To investigate the differences in expressed emotion among families of patients with Schizophrenia and develop an instrument for expressed emotion. A sample of 35 families was selected by using non-probability sampling technique. It was hypothesized that there would be significant difference in expressed emotion among families of patients with schizophrenia and families of normal subjects. A questionnaire based on Likert Scale technique was used to measure expressed emotion of the families. Those members were selected who have spent at least 35 hours with the patient. Independent t-test was performed to see the difference in their expressed emotion on criticism, hostility, positive remarks, warmth and emotional overinvolvement. Descriptive statistics was used to find out the relationship between demographic variables. The research finding showed a significant difference in expressed emotion between parents of schizophrenics and parents of normal subjects. This is the first study on expressed emotions in Pakistani perspective and provides guidelines for future management in schizophrenia