This retrospective cohort study was conducted from January 23, 2017, to October 21, 2019. Participants consisted of 106 male, active-duty US Army or law enforcement personnel who had routinely conducted heavy-wall breaching, used a 0.50-caliber sniper rifle, and/or participated in hand-grenade-throwing exercises during their career to date. Eligible participants consisted of personnel aged 18 years or older from 4 US Department of Defense and civilian law enforcement training sites who were present and willing to participate during an occupational training course and were actively assigned as “fit for duty” as determined by supervising staff. Personnel who were younger than 18 years were excluded. There were no female participants engaged in training at the time of study enrollment. Written informed consent was obtained from these participants before all procedures and testing. Serum samples from controls, comprising healthy men without disease, were obtained from a vendor, BioIVT, and chosen to match median age criteria based on availability from the vendor; informed consent was not available for these samples. The study was approved by the Walter Reed Army Institute of Research institutional review board and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.25,26

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