homozygous 'Cl phenotype-and MGUS might just be a casual coincidence. However, at least three hypotheses can be discussed to explain the relationship between MGUS and or l AT deficiency. First, the genes for immunoglobulin heavy chains have been shown to be linked to the locus for or l AT on chromosome 14 6 • Second, or l AT may have a direct effect on immunoregulation and the relation between a l AT deficiency and some immune disorders has already been documented". It is possible that the generalized hyperresponsiveness of the immune pathway in or l AT deficiency could account for the appearance of MGUS through chronic antigenic stimulation. Finally, such chronic antigenic stimulation could be due to subclinical pulmonary or hepatic impairment induced by a l AT deficiency", although our patient did not show any evidence of disease in these systems. References

The incidence of tracheal stenosis following conventional tracheostomy has been reported as lying between one and 30 per cent. Methods used to assess the degree of stenosis include CT scanning, fibreoptic visualization and plain X-ray tomographs. The aim of this study was to assess the degree of stenosis in patients following percutaneous dilatational tracheostomy (PDT) using MRI scanning. This method has not been reported in the literature previously. Nine patients without symptoms of tracheal stenosis were studied for at least six months following PDT performed in the intensive therapy unit. The tracheas were assessed for scarring and stenosis using a three dimensional volume scanning MRI technique. Although scarring could be detected in the wall of the trachea and subcutaneous tissues of all patients, tracheal stenosis was not demonstrated at the insertion site or at the site of the cuff (p>0.05). MRI scanning provides an excellent non-invasive method of assessing the tracheal lumen. Our patients who had undergone PDT do not appear to have any degree of post-operative stenosis.

Until the law in the United Kingdom (UK) changed in May 2016 so called ''legal highs'' or ''new psychoactive substances'' were freely available in high street shops across the UK. Following prohibition these drugs are still easily purchased illegally via the internet. We report a case of a patient who self-administered 3-fluorophenmetrazine intravenously with catastrophic consequences. Adverse effects were almost immediate with symptoms of malaise and tachycardia. Two days post administration he was transferred to the intensive therapy unit with acute kidney injury and irreversible four limb ischaemia. He required a period of renal replacement therapy and bilateral lower limb amputation. This case highlights the fact that new psychoactive substances have many unintended adverse effect which have not been previously described. Multiple routes of administration are used by people taking these agents including intravenously. Medical practitioners should always consider ingestion of new psychoactive substances in the differential diagnosis of acutely ill patients.

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