{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T06:10:01Z","timestamp":1778652601609,"version":"3.51.4"},"reference-count":40,"publisher":"Oxford University Press (OUP)","license":[{"start":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T00:00:00Z","timestamp":1778630400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Department of War, through the Psychological Health\/Traumatic Brain Injury Research Program Long-Term Impact of Military-Relevant Brain Injury Consortium","award":["W81XWH-18-PH\/TBIRP-LIMBIC"],"award-info":[{"award-number":["W81XWH-18-PH\/TBIRP-LIMBIC"]}]},{"name":"Department of War, through the Psychological Health\/Traumatic Brain Injury Research Program Long-Term Impact of Military-Relevant Brain Injury Consortium","award":["W81XWH1920067"],"award-info":[{"award-number":["W81XWH1920067"]}]},{"name":"Department of War, through the Psychological Health\/Traumatic Brain Injury Research Program Long-Term Impact of Military-Relevant Brain Injury Consortium","award":["W81XWH-13-2-0095"],"award-info":[{"award-number":["W81XWH-13-2-0095"]}]},{"DOI":"10.13039\/100000738","name":"US Department of Veterans Affairs","doi-asserted-by":"publisher","award":["I01 RX003443"],"award-info":[{"award-number":["I01 RX003443"]}],"id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]},{"DOI":"10.13039\/100007217","name":"VA Health Services Research and Development Service","doi-asserted-by":"publisher","award":["IHX002608A"],"award-info":[{"award-number":["IHX002608A"]}],"id":[{"id":"10.13039\/100007217","id-type":"DOI","asserted-by":"publisher"}]},{"name":"VA HSR&D Informatics, Decision-Enhancement, and Analytic Sciences Center of Innovation","award":["13-414"],"award-info":[{"award-number":["13-414"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Introduction<\/jats:title>\n                    <jats:p>Military occupational blast and impulse exposure (MOBE) is a potential risk factor for increased Anger, Aggression, or Violence (AAV). The objective of this study was to assess the association between MOBE and AAV-related content in clinical text notes in Veterans Health Administration (VHA) data.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and Methods<\/jats:title>\n                    <jats:p>This matched cohort study investigated AAV-related content in clinical text data from Veterans across high and low-risk MOBE occupations. Veterans with documentation of high-risk MOBE occupations were sampled from a VHA population database and matched 1:1 with low-risk MOBE controls on age, sex, and race\/ethnicity. An algorithm leveraging semantic similarity and large language models (LLMs) identified AAV content in millions of VHA clinical text notes. Model performance was assessed by manual review. Veteran outcomes were classified as AAV-positive or AAV-negative based on the content of their medical records. Logistic regression was used to estimate the association between MOBE and AAV.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among the MOBE cohort (n\u2009=\u20095,000) and matched controls (n\u2009=\u20095,000), 3.64 million clinical notes (Mean: 364 notes\/person) were classified using an LLM pipeline that achieved 96% classification accuracy in manual review. Raw group differences were significant, with 17.2% of the MOBE cohort meeting AAV criteria, compared to 12.0% of matched controls (unadjusted Odds Ratio [OR]: 1.53 [1.37-1.71]). In adjusted models, the association between MOBE and AAV remained significant (OR: 1.22 [1.08-1.38]). Combat exposure (OR: 1.32 [1.11-1.58]) and traumatic brain injury (TBI) (OR: 1.47 [1.29-1.67]) were associated with increased AAV, while female sex was protective (OR: 0.33 [0.24-0.45]). In nested models, the OR for AAV ranged from 1.53 to 1.16 depending on the covariates considered, and posttraumatic stress disorder (PTSD) was found to be a significant confounder of the MOBE-AAV association.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>This matched cohort study found that individuals who served in occupations at high risk for MOBE were significantly more likely to have evidence of AAV in clinical text data. Neurological and affective changes potentially linked to MOBE may be interconnected with other military health factors, such as combat exposure, TBI, and PTSD.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1093\/milmed\/usag217","type":"journal-article","created":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T11:44:26Z","timestamp":1777031066000},"source":"Crossref","is-referenced-by-count":0,"title":["When the Fuse Is Lit: Association of Military Occupational Blast Exposure With Anger, Aggression, and Violence"],"prefix":"10.1093","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-9211-1271","authenticated-orcid":false,"given":"Eamonn","family":"Kennedy","sequence":"first","affiliation":[{"name":"Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System , Salt Lake City, UT 84148,","place":["United States"]},{"name":"Division of Epidemiology, Department of Internal Medicine, University of Utah , Salt Lake City, UT 84108,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shashank","family":"Vadlamani","sequence":"additional","affiliation":[{"name":"Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System , Salt Lake City, UT 84148,","place":["United States"]},{"name":"Division of Epidemiology, Department of Internal Medicine, University of Utah , Salt Lake City, UT 84108,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Megan","family":"Amuan","sequence":"additional","affiliation":[{"name":"Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System , Salt Lake City, UT 84148,","place":["United States"]},{"name":"Division of Epidemiology, Department of Internal Medicine, University of Utah , Salt Lake City, UT 84108,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ian J","family":"Stewart","sequence":"additional","affiliation":[{"name":"Department of Medicine, Uniformed Services University of Health Sciences , Bethesda, MD 20814,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Shannon R","family":"Miles","sequence":"additional","affiliation":[{"name":"Mental Health and Behavioral Sciences Service, James A Haley Veterans\u2019 Hospital, Tampa , Tampa, FL 33612,","place":["United States"]},{"name":"Psychiatry and Behavioral Neurosciences, Morsani College of Medicine, University of South Florida , Tampa, FL 33613,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sarah L","family":"Martindale","sequence":"additional","affiliation":[{"name":"Salisbury VA Healthcare System , Salisbury, NC 28144,","place":["United States"]},{"name":"Veterans Integrated Service Networks (VISN)-6 Mid-Atlantic Mental Illness, Research Education and Clinical Center (MIRECC) , Durham, NC 27705,","place":["United States"]},{"name":"Department of Translational Neuroscience, Wake Forest School of Medicine , Winston-Salem, NC 27101,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Lisa A","family":"Brenner","sequence":"additional","affiliation":[{"name":"VA Brain Health Coordinating Center , Aurora, CO 80045,","place":["United States"]},{"name":"Department of Physical Medicine and Rehabilitation, University of Colorado , Aurora, CO 80045,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mary Jo","family":"Pugh","sequence":"additional","affiliation":[{"name":"Informatics, Decision-Enhancement and Analytic Sciences (IDEAS) Center of Innovation, Veterans Affairs Salt Lake City Health Care System , Salt Lake City, UT 84148,","place":["United States"]},{"name":"Division of Epidemiology, Department of Internal Medicine, University of Utah , Salt Lake City, UT 84108,","place":["United States"]}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"286","published-online":{"date-parts":[[2026,5,13]]},"reference":[{"key":"2026051301221783600_usag217-B1","doi-asserted-by":"publisher","first-page":"3222","DOI":"10.1089\/neu.2021.0059","article-title":"Phenotyping the spectrum of traumatic brain injury: a review and pathway to standardization","volume":"38","author":"Pugh","year":"2021","journal-title":"J Neurotrauma"},{"key":"2026051301221783600_usag217-B2","doi-asserted-by":"publisher","first-page":"1169822","DOI":"10.3389\/fneur.2023.1169822","article-title":"Challenges in measuring military occupational blast exposure: self-report, proxy, and objective approaches","volume":"14","author":"Rowland","year":"2023","journal-title":"Front Neurol"},{"key":"2026051301221783600_usag217-B3","doi-asserted-by":"publisher","first-page":"e538","DOI":"10.1093\/milmed\/usz289","article-title":"Blast exposure and risk of recurrent occupational overpressure exposure predict deployment TBIs","volume":"185","author":"Belding","year":"2020","journal-title":"Mil Med"},{"key":"2026051301221783600_usag217-B4","doi-asserted-by":"publisher","first-page":"695496","DOI":"10.3389\/fneur.2021.720219","article-title":"Getting on the same page: consolidating terminology to facilitate cross-disciplinary health-related blast research","volume":"12","author":"Belding","year":"2021","journal-title":"Front Neurol"},{"key":"2026051301221783600_usag217-B5","doi-asserted-by":"publisher","first-page":"2468","DOI":"10.1089\/neu.2020.7141","article-title":"Functional and structural neuroimaging correlates of repetitive low-level blast exposure in career breachers","volume":"37","author":"Stone","year":"2020","journal-title":"J Neurotrauma"},{"key":"2026051301221783600_usag217-B6","doi-asserted-by":"publisher","first-page":"942","DOI":"10.1089\/neu.2023.0309","article-title":"Neurological effects of repeated blast exposure in special operations personnel","volume":"41","author":"Stone","year":"2024","journal-title":"J Neurotrauma"},{"key":"2026051301221783600_usag217-B7","doi-asserted-by":"publisher","first-page":"e2069","DOI":"10.1093\/milmed\/usae082","article-title":"Cumulative blast impulse is predictive for changes in chronic neurobehavioral symptoms following low-level blast exposure during military training","volume":"189","author":"McEvoy","year":"2024","journal-title":"Mil Med"},{"key":"2026051301221783600_usag217-B8","doi-asserted-by":"publisher","first-page":"1599351","DOI":"10.3389\/fneur.2025.1599351","article-title":"Blast exposure and long-term diagnoses among veterans: a millennium cohort study investigation of high-level blast and low-level blast","volume":"16","author":"Martindale","year":"2025","journal-title":"Front Neurol"},{"key":"2026051301221783600_usag217-B9","author":"Philipps"},{"key":"2026051301221783600_usag217-B10","author":"Philipps"},{"key":"2026051301221783600_usag217-B11","doi-asserted-by":"publisher","first-page":"1055","DOI":"10.1037\/tra0001498","article-title":"Clinical correlates of irritability, anger, hostility, and aggression in posttraumatic stress disorder","volume":"16","author":"Zhan","year":"2024","journal-title":"Psychol Trauma"},{"key":"2026051301221783600_usag217-B12","doi-asserted-by":"publisher","first-page":"57","DOI":"10.1016\/j.jpsychires.2022.04.004","article-title":"Problem anger in veterans and military personnel: prevalence, predictors, and associated harms of suicide and violence","volume":"151","author":"Varker","year":"2022","journal-title":"J Psychiatr Res"},{"key":"2026051301221783600_usag217-B13","doi-asserted-by":"publisher","first-page":"2091","DOI":"10.1056\/NEJMoa1008069","article-title":"Detection of blast-related traumatic brain injury in U.S. military personnel","volume":"364","author":"Mac Donald","year":"2011","journal-title":"N Engl J Med"},{"key":"2026051301221783600_usag217-B14","doi-asserted-by":"publisher","first-page":"1383710","DOI":"10.3389\/fneur.2024.1383710","article-title":"Considerations for the assessment of blast exposure in service members and veterans","volume":"15","author":"Rowland","year":"2024","journal-title":"Front Neurol"},{"key":"2026051301221783600_usag217-B15","doi-asserted-by":"publisher","first-page":"2321","DOI":"10.1089\/neu.2023.0067","article-title":"Validation of military occupational specialty as a proxy for blast exposure using the salisbury blast interview","volume":"40","author":"Martindale","year":"2023","journal-title":"J Neurotrauma"},{"key":"2026051301221783600_usag217-B16","doi-asserted-by":"publisher","first-page":"619","DOI":"10.3389\/fneur.2020.00619","article-title":"Association of MOS-based blast exposure with medical outcomes","volume":"11","author":"Carr","year":"2020","journal-title":"Front Neurol"},{"key":"2026051301221783600_usag217-B17","doi-asserted-by":"publisher","first-page":"117","DOI":"10.1186\/s12911-025-02954-4","article-title":"A systematic review of large language model (LLM) evaluations in clinical medicine","volume":"25","author":"Shool","year":"2025","journal-title":"BMC Med Inform Decis Mak"},{"key":"2026051301221783600_usag217-B18","doi-asserted-by":"publisher","first-page":"8236","DOI":"10.1038\/s41467-024-52415-1","article-title":"Evaluating the use of large language models to provide clinical recommendations in the emergency department","volume":"15","author":"Williams","year":"2024","journal-title":"Nat Commun"},{"key":"2026051301221783600_usag217-B19","first-page":"167","article-title":"Transfer learning with clinical concept embeddings from large language models","volume":"2025","author":"Gao","year":"2025","journal-title":"AMIA Jt Summits Transl Sci Proc"},{"key":"2026051301221783600_usag217-B20","doi-asserted-by":"publisher","first-page":"1389757","DOI":"10.3389\/fneur.2024.1389757","article-title":"Traumatic brain injury and occupational risk of low-level blast exposure on adverse career outcomes: an examination of administrative and medical separations from service (2005\u20132015)","volume":"15","author":"Belding","year":"2024","journal-title":"Front Neurol"},{"key":"2026051301221783600_usag217-B21","doi-asserted-by":"publisher","first-page":"e2148150","DOI":"10.1001\/jamanetworkopen.2021.48150","article-title":"Association of traumatic brain injury with mortality among military veterans serving after September 11, 2001","volume":"5","author":"Howard","year":"2022","journal-title":"JAMA Netw Open"},{"key":"2026051301221783600_usag217-B22","doi-asserted-by":"publisher","first-page":"1097","DOI":"10.1162\/coli_a_00524","article-title":"Bias and fairness in large language models: a survey","volume":"50","author":"Gallegos","year":"2024","journal-title":"Comput Linguist"},{"key":"2026051301221783600_usag217-B23","author":"Google. google\/gemma-2-9b [Large language model]","year":"2024"},{"key":"2026051301221783600_usag217-B24","doi-asserted-by":"publisher","first-page":"S25","DOI":"10.1016\/j.biopsych.2025.02.078","article-title":"Natural language processing to enable cross-scale harmonization supporting symptom domain analyses","volume":"97","author":"Dennis","year":"2025","journal-title":"Biol Psychiatry"},{"key":"2026051301221783600_usag217-B25","doi-asserted-by":"publisher","author":"Wolf","year":"2020","DOI":"10.18653\/v1\/2020.emnlp-demos.6"},{"key":"2026051301221783600_usag217-B26","doi-asserted-by":"publisher","first-page":"1008","DOI":"10.1089\/neu.2024.0301","article-title":"Linking symptom inventories using semantic textual similarity","volume":"42","author":"Kennedy","year":"2025","journal-title":"J Neurotrauma"},{"key":"2026051301221783600_usag217-B27","author":"Ollama, Inc","year":"2024"},{"key":"2026051301221783600_usag217-B28","doi-asserted-by":"publisher","first-page":"1168","DOI":"10.1186\/s12889-020-09206-2","article-title":"Magnitude of problematic anger and its predictors in the millennium cohort","volume":"20","author":"Adler","year":"2020","journal-title":"BMC Public Health"},{"key":"2026051301221783600_usag217-B29","doi-asserted-by":"publisher","first-page":"453","DOI":"10.1212\/WNL.0000000000012409","article-title":"Risk of posttraumatic seizures and epilepsy after traumatic brain injury: a review","volume":"97","author":"Stein","year":"2021","journal-title":"Neurology"},{"key":"2026051301221783600_usag217-B30","doi-asserted-by":"publisher","first-page":"141","DOI":"10.1176\/jnp.18.2.141","article-title":"Blast-related traumatic brain injury: what is known?","volume":"18","author":"Taber","year":"2006","journal-title":"J Neuropsychiatry Clin Neurosci"},{"key":"2026051301221783600_usag217-B31","doi-asserted-by":"publisher","first-page":"269","DOI":"10.3389\/fneur.2014.00269","article-title":"Effects of low-level blast exposure on the nervous system: is there really a controversy?","volume":"5","author":"Elder","year":"2014","journal-title":"Front Neurol"},{"key":"2026051301221783600_usag217-B32","first-page":"S45","article-title":"Assessment of the effects of blast overpressure on the brain","volume":"54","author":"Ahlers","year":"2012","journal-title":"Neuroimage"},{"key":"2026051301221783600_usag217-B33","doi-asserted-by":"publisher","first-page":"81","DOI":"10.1016\/j.apmr.2019.07.018","article-title":"Posttraumatic stress disorder symptoms contribute to provider perceived anger, irritability, and aggression after TBI: a VA TBI model systems study","volume":"101","author":"Miles","year":"2020","journal-title":"Arch Phys Med Rehabil"},{"key":"2026051301221783600_usag217-B34","doi-asserted-by":"publisher","first-page":"947","DOI":"10.1089\/neu.2010.1548","article-title":"Blast exposure in rats with body shielding is characterized primarily by diffuse axonal injury","volume":"28","author":"Garman","year":"2011","journal-title":"J Neurotrauma"},{"key":"2026051301221783600_usag217-B35","doi-asserted-by":"publisher","first-page":"255","DOI":"10.1038\/jcbfm.2009.203","article-title":"Traumatic brain injury: an overview of pathobiology with emphasis on military populations","volume":"30","author":"Cernak","year":"2010","journal-title":"J Cereb Blood Flow Metab"},{"key":"2026051301221783600_usag217-B36","doi-asserted-by":"publisher","first-page":"S242","DOI":"10.1016\/j.jalz.2014.04.003","article-title":"Military-related traumatic brain injury and neurodegeneration","volume":"10","author":"McKee","year":"2014","journal-title":"Alzheimers Dement"},{"key":"2026051301221783600_usag217-B37","volume-title":"Hearing Loss: Determining Eligibility for Social Security Benefits","author":"National Research Council (US) Committee on Disability Determination for Individuals with Hearing Impairments","year":"2004"},{"key":"2026051301221783600_usag217-B38","doi-asserted-by":"publisher","first-page":"173","DOI":"10.1016\/bs.pbr.2021.01.005","article-title":"Infrasound exposure and human neurophysiology: a review","volume":"263","author":"Maher","year":"2021","journal-title":"Prog Brain Res"},{"key":"2026051301221783600_usag217-B39","doi-asserted-by":"publisher","first-page":"3549","DOI":"10.3390\/ijms25063549","article-title":"Association of blast exposure in military breaching with intestinal permeability blood biomarkers associated with leaky gut","volume":"25","author":"Liu","year":"2024","journal-title":"Int J Mol Sci"},{"key":"2026051301221783600_usag217-B40","doi-asserted-by":"publisher","first-page":"237","DOI":"10.1016\/j.avb.2005.09.002","article-title":"Sex differences in direct aggression: what are the psychological mediators?","volume":"11","author":"Campbell","year":"2006","journal-title":"Aggress Violent Behav"}],"container-title":["Military Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag217\/68277017\/usag217.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article-pdf\/doi\/10.1093\/milmed\/usag217\/68277017\/usag217.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,13]],"date-time":"2026-05-13T05:22:25Z","timestamp":1778649745000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/milmed\/advance-article\/doi\/10.1093\/milmed\/usag217\/8677075"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,13]]},"references-count":40,"URL":"https:\/\/doi.org\/10.1093\/milmed\/usag217","relation":{},"ISSN":["0026-4075","1930-613X"],"issn-type":[{"value":"0026-4075","type":"print"},{"value":"1930-613X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,13]]},"article-number":"usag217"}}