機能性ディスペプシア（FD）の症状は胃の運動機能異常や内臓知覚過敏性により説明される．FD の本態は十二指腸粘膜の微小炎症にあるとされており，我われは，脳腸相関による，ストレス由来の原因と腸管局所の末梢性由来の微小炎症があると想定している．十二指腸局所には，内臓知覚過敏と深く関与している，protease activated protein 2 (PAR2) を介した，trypsin-PAR2 pathway によって，十二指腸の微細炎症が誘導されると考えている．この微細炎症が十二指腸の胃酸，胆汁酸，trypsin などの刺激に対する感受性を高めていると考えられている．我われは，難治性FD 患者のうちには膵酵素異常を伴うFD 患者や早期慢性膵炎患者が包含されていると考えている．最近，この早期慢性膵炎患者から膵癌へと移行した症例を経験した．したがって，難治性FD 患者に対し，積極的に膵酵素の測定を行うと共に，膵酵素異常を伴う心窩部痛患者に対して，積極的に超音波内視鏡検査を用いた診察を行うことを推奨したい．

　A 47-year-old woman was transferred to our hospital after experiencing cardiogenic shock and undergoing intra-aortic balloon pumping. The patient had received the first dose of the messenger RNA (mRNA)-1273 vaccine (Moderna) before hospitalization. Echocardiography revealed a reduced left ventricular ejection fraction and massive biventricular thrombi. Cardiac magnetic resonance imaging suggested myocarditis. After the ventricular thrombus was resolved, an endomyocardial biopsy confirmed the diagnosis of myocarditis. Finally, we terminated the intravenous inotrope therapy. Although fulminant myocarditis with biventricular thrombi after mRNA vaccination for coronavirus disease 2019 is extremely rare, post-vaccination myocarditis should be considered in the differential diagnosis of a cardiogenic shock.

　In 1978, we reported a case of severe primary pulmonary hypertension (PH) in a 14-year-old girl. Initial cardiac catheterization revealed severe PH and pulmonary arterial pressure (Ppa) of 145/65 (100) mmHg. Twenty-four-hour monitoring revealed a decrease in Ppa with administration of supplemental oxygen and alpha-blockade. After that, she was treated with vasodilating drugs including alpha-blockade and home oxygen therapy. She survived for 45 years with only mild exertional dyspnea, except during her last few years. At 1 month before death, her Ppa was 160/44 (82). A chest X-ray revealed almost the same cardiac configuration as that observed on her initial visit. This is the longest survival seen in a patient with idiopathic pulmonary arterial hypertension and an extremely high Ppa.