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Objective: Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is managed by standard endoscopic combination therapy, but a few cases remain difficult and carry a high risk of persistent or recurrent bleeding. The aim of our study was to compare first-line over-the-scope-clips (OTSC) therapy with standard endoscopic treatment in these selected patients., Design: We conducted a prospective, randomised, controlled, multicentre study (NCT03331224). Patients with endoscopic evidence of acute NVUGIB and high risk of rebleeding (defined as complete Rockall Score ≥7) were included. Primary endpoint was clinical success defined as successful endoscopic haemostasis without evidence of recurrent bleeding., Results: 246 patients were screened and 100 patients were finally randomised (mean of 5 cases/centre and year; 70% male, 30% female, mean age 78 years; OTSC group n=48, standard group n=52). All but one case in the standard group were treated with conventional clips. Clinical success was 91.7% (n=44) in the OTSC group compared with 73.1% (n=38) in the ST group (p=0.019), with persistent bleeding occurring in 0 vs 6 in the OTSC versus standard group (p=0.027), all of the latter being successfully managed by rescue therapy with OTSC. Recurrent bleeding was observed in four patients (8.3%) in the OTSC group and in eight patients (15.4%) in the standard group (p=0.362)., Conclusion: OTSC therapy appears to be superior to standard treatment with clips when used by trained physicians for selected cases of primary therapy of NVUGIB with high risk of rebleeding. Further studies are necessary with regards to patient selection to identify subgroups benefiting most from OTSC haemostasis., Trial Registration Number: NCT03331224., Competing Interests: Competing interests: BM received fees for research activities and lecture fees from Ovesco Endoscopy AG. AM is a consultant for Ovesco Endoscopy AG and received lecture fees from Ovesco Endoscopy AG. AS received lecture fees and study grants from Ovesco Endoscopy AG. EW and KC received lecture fees from Ovesco Endoscopy AG. AW, UD, PS, BS, DA, AH, JF, BMW, MZ, TP and AK have no disclosures to report., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

History: A 71-year-old man with Richter's syndrome (transformation of chronic lymphocytic leukemia [CLL] to diffuse large B-cell lymphoma) was admitted to our hospital to get his second cycle of rituximab/bendamustin treatment. He had been diagnosed with Richter's syndrome three months earlier: a bulky tumor was seen on the backside of the stomach in a routine gastroscopy. Taking a biopsy had resulted in a major bleeding impossible to stop endoscopically. An emergency surgical multi-visceral resection was performed. The first cycle of chemotherapy was administered about 4 weeks prior to the present appointment., Investigations: In the physical examination the patient showed a bad orientation and confusion together with a skinny habitus. The initially performed lab tests and a CT-Scan of the brain did not show a significant finding. A mini-mental-state-examination (MMSE) showed moderate cognitive impairment. In a psychiatric consultation the patient was diagnosed with reactive depression and a corresponding medication was given. After the second cycle of chemotherapy the patient's state of mind decreased markedly within days. DIAGNOSIS, TREATMENT AND FURTHER COURSE: The further diagnostic investigation (MRI of the brain, lumbar puncture) brought the diagnosis of progressive multifocal leukoencephalopathy. The administration of chemotherapy was stopped then. Three weeks after the diagnosis the patient died in the hospice., Conclusion: If a patient develops neurological or psychiatric symptoms during therapy with rituximab clinicians should be aware of the potential diagnosis of PML and initiate further investigations., (© Georg Thieme Verlag KG Stuttgart · New York.)

The Giacomini vein is present in 2.5%-10% of all patients having a phlebography because of varicosis. In a patient analysis of the last 5 years 129 patients were detected with a Giacomini vein (2.5%) out of a total of 5132 patients with varicosis. This vein was found in a significantly higher number of patients with a combined insufficiency of the long and short saphenous vein (p = 0.0001). An analysis of the different insufficiency patterns showed a Giacomini vein in 80% of insufficiency of grade I of the long and short saphenous vein. Likewise, this vein could be detected in more than half of the cases with complete insufficiency of both venous trunks (51%) as well as in 55% of the patients with a short saphenous vein insufficiency of grade III and an incomplete insufficiency of the long saphenous vein. On the other hand, there was no connection between insufficiency of the long saphenous vein, incomplete insufficiency of the short saphenous vein and the presence of the Giacomini vein. From these results we draw the conclusion that the Giacomini vein is a pathophysiologic connection between the two providing areas and thus transfers the insufficiency from one vascular system to the other. It hereby enhances the combined varicosis of both trunks as well as the formation of relapses. Therefore the Giacomini vein should always be stripped or removed by exeresis.