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AAC can be assessed on dual-energy X-ray absorptiometry (DXA)-derived lateral spine images used for vertebral fracture assessment at the time of bone density screening using a validated 24-point scoring method (AAC-24). Previous studies have identified robust associations between AAC-24 score, incident falls, and fractures. However, a major limitation of manual AAC assessment is that it requires a trained expert. Hence, we have developed an automated machine-learning algorithm for assessing AAC-24 scores (ML-AAC24). In this prospective study, we evaluated the association between ML-AAC24 and long-term incident falls and fractures in 1023 community-dwelling older women (mean age, 75\u2009\u00b1\u20093\u2009years) from the Perth Longitudinal Study of Ageing Women. Over 10\u2009years of follow-up, 253 (24.7%) women experienced a clinical fracture identified via self-report every 4\u20136\u2009months and verified by X-ray, and 169 (16.5%) women had a fracture hospitalization identified from linked hospital discharge data. Over 14.5\u2009years, 393 (38.4%) women experienced an injurious fall requiring hospitalization identified from linked hospital discharge data. After adjusting for baseline fracture risk, women with moderate to extensive AAC (ML-AAC24\u2009\u2265\u20092) had a greater risk of clinical fractures (hazard ratio [HR] 1.42; 95% confidence interval [CI], 1.10\u20131.85) and fall-related hospitalization (HR 1.35; 95% CI, 1.09\u20131.66), compared to those with low AAC (ML-AAC24\u2009\u2264\u20091). Similar to manually assessed AAC-24, ML-AAC24 was not associated with fracture hospitalizations. The relative hazard estimates obtained using machine learning were similar to those using manually assessed AAC-24 scores. In conclusion, this novel automated method for assessing AAC, that can be easily and seamlessly captured at the time of bone density testing, has robust associations with long-term incident clinical fractures and injurious falls. However, the performance of the ML-AAC24 algorithm needs to be verified in independent cohorts. \u00a9 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).<\/jats:p>","DOI":"10.1002\/jbmr.4921","type":"journal-article","created":{"date-parts":[[2023,10,12]],"date-time":"2023-10-12T08:36:28Z","timestamp":1697099788000},"page":"1867-1876","update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":21,"title":["Machine-Learning Assessed Abdominal Aortic Calcification is Associated with Long-Term Fall and Fracture Risk in Community-Dwelling Older Australian Women"],"prefix":"10.1093","volume":"38","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-1815-0838","authenticated-orcid":false,"given":"Jack","family":"Dalla Via","sequence":"first","affiliation":[{"name":"Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences Edith Cowan University Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1975-0085","authenticated-orcid":false,"given":"Abadi K.","family":"Gebre","sequence":"additional","affiliation":[{"name":"School of Pharmacy, College of Health Sciences Mekelle University Mekelle Ethiopia"},{"name":"Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences Edith Cowan University Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2517-2824","authenticated-orcid":false,"given":"Cassandra","family":"Smith","sequence":"additional","affiliation":[{"name":"Medical School The University of Western Australia Perth Western Australia Australia"},{"name":"Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences Edith Cowan University Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7448-2327","authenticated-orcid":false,"given":"Zulqarnain","family":"Gilani","sequence":"additional","affiliation":[{"name":"Department of Computer Science and Software Engineering the University of Western Australia Perth Western Australia Australia"},{"name":"Centre for Artificial Intelligence and Machine Learning, School of Science Edith Cowan University Perth Western Australia Australia"},{"name":"Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences Edith Cowan University Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6306-3023","authenticated-orcid":false,"given":"David","family":"Suter","sequence":"additional","affiliation":[{"name":"Centre for Artificial Intelligence and Machine Learning, School of Science Edith Cowan University Perth Western Australia Australia"},{"name":"Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences Edith Cowan University Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8351-6288","authenticated-orcid":false,"given":"Naeha","family":"Sharif","sequence":"additional","affiliation":[{"name":"Department of Computer Science and Software Engineering the University of Western Australia Perth Western Australia Australia"},{"name":"Centre for Artificial Intelligence and Machine Learning, School of Science Edith Cowan University Perth Western Australia Australia"},{"name":"Nutrition and Health Innovation Research Institute, School of Medical and Health Sciences Edith Cowan University Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4168-6697","authenticated-orcid":false,"given":"Pawel","family":"Szulc","sequence":"additional","affiliation":[{"name":"INSERM UMR 1033 University of Lyon Lyon France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9329-0750","authenticated-orcid":false,"given":"John T.","family":"Schousboe","sequence":"additional","affiliation":[{"name":"Park Nicollet Clinic and HealthPartners Institute, HealthPartners, Minneapolis, USA and Division of Health Policy and Management University of Minnesota Minneapolis MN USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8474-0310","authenticated-orcid":false,"given":"Douglas P.","family":"Kiel","sequence":"additional","affiliation":[{"name":"Hinda and Arthur Marcus Institute for Aging Research, Hebrew Senior Life, Department of Medicine, Beth Israel Deaconess Medical Center Harvard Medical School Boston MA USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8723-7574","authenticated-orcid":false,"given":"Kun","family":"Zhu","sequence":"additional","affiliation":[{"name":"Department of Endocrinology and Diabetes Sir Charles Gairdner Hospital Perth Western Australia Australia"},{"name":"Medical School The University of Western Australia Perth Western Australia Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1056-1691","authenticated-orcid":false,"given":"William D.","family":"Leslie","sequence":"additional","affiliation":[{"name":"Departments of Medicine and Radiology University of Manitoba Winnipeg MB Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2298-4202","authenticated-orcid":false,"given":"Richard 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