Anesthetic risk factors include the use of volatile anesthetics, nitrous oxide (N2O), opioids, and longer duration of anesthesia. Patient factors that confer increased risk for PONV include female gender, obesity, age less than 16 years, past history of motion sickness or chemotherapy-induced nausea, high levels of preoperative anxiety, and patients with history of PONV. Smokers and the elderly often have a decreased risk for PONV. A risk-stratification method created by Apfel et al has been developed to determine a patients risk for PONV. The presence of 0, 1, 2, 3, or 4 of any of the following risk factors corresponds to a PONV respective risk of 10, 20, 40, 60, and 80%.- Female gender
- Non-smoking
- History of PONV or motion sickness
- Expectant use of postoperative opioid medications

Prevention
Treatment options to prevent PONV include medications such as antiemetics (for example, ondansetron or dexamethasone) or other drugs including tropisetron, dolasetron, cyclizine, and granisetron. Droperidol may cause QT prolongation and is not frequently used. Other approaches to reduce PONV include decision on the types of anaesthetic used during surgery and intravenous (IV) dextrose solutions. Increasing the IV fluids during surgery by giving additional fluid while the person is under general anaesthesia may reduce the risk of nausea/vomiting after surgery. For minor surgical procedures, more research is needed to determine the risks and benefits of this approach. Management
Because  currently no single antiemetic available is especially effective on its own, experts recommend a multimodal approach.
Marjolins ulcer refers to an aggressive ulcerating squamous cell carcinoma presenting in an area of previously traumatized, chronically inflamed, or scarred skin. : 737   They are commonly present in the context of chronic wounds including burn injuries, varicose veins, venous ulcers, ulcers from osteomyelitis, and post radiotherapy scars. The term was named after French surgeon, Jean-Nicolas Marjolin, who first described the condition in 1828. The term was later coined by J C De Costa. Presentation
Slow growth, painlessness (as the ulcer is usually not associated with nerve tissue), and absence of lymphatic spread due to local destruction of lymphatic channels. Histology
Histologically, the tumour is a well-differentiated squamous cell carcinoma. This carcinoma is aggressive in nature, spreads locally and is associated with a poor prognosis. The cancer has a 18-38% rate of metastasis. 40% occur on the lower limb and the malignant change is usually painless. This malignant change of the wound happens a long time after initial trauma, usually 10–25 years later. Its edge is everted and not always raised. More recent transcriptional analysis suggests that chronically impeded extracellular matrix turnover and epithelium-to-mesenchyme transitions in neglected scar tissue might give rise to this malignancy. Diagnosis
Wedge biopsy is the favored method of diagnosis. Tissue specimens obtained should be taken from both the centre and margin of lesion, as the central ulcerated deposits may be necrotic. Treatment
Treatment is usually surgical, with a wide excision of the lesion; typically a 1 cm margin all around is required. See also
Saree cancer

References


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