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ary, we observed a close link between the increase in certain immune escape-associated mutations and the development of resistance mutations. sA159V might increase the fitness of LAM/ETV-resistant mutants under environmental pressure in some cases. The incidence of peptic ulcer disease has decreased during the last few decades, but the incidence of reported peptic ulcer complications has not decreased. Perforating peptic ulcer (PPU) is a severe form of the disease. To assess trends in the incidence, presentation, and outcome of PPU