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Background
Braided, twisted, and locs (BTL) hairstyles, can present as artifacts, thus posing unique diagnostic challenges in interpreting radiographic imaging. Artifacts can impact the quality and accuracy of medical imaging, which can affect patient care, diagnosis, and treatment outcomes. Unfortunately, limited research has been conducted on how different Black hairstyles and textures impact radiological imaging, or how this affects patients’ experience, including time they spent in the hospital and/or unnecessary radiation exposure as a result. In this study, we explore how common Black hairstyles appear in radiological imaging from plain film radiography to CT and MRI and evaluate the unique artifacts and challenges certain hairstyles pose in diagnostic imaging. Further, we strive to gauge the current level of knowledge physicians have with identification of Black hair in radiological imaging.

Educational Goals / Teaching Points
Present a review of literature and survey results of physicians and technicians’ comfortability, familiarity, and validity of assessing Black hairstyles as hair artifact on plan radiological films (chest x-rays). BTL hairstyles have been observed to introduce shadows or artifacts that can compromise the clarity of radiographic images. The tightness and density of these styles represent a spectrum of artifacts for which even optimal positioning may still compromise the image quality. These extensions commonly feature a coating of oils aimed at preserving their sheen and moisture. It is precisely the presence of these oils that can give rise to peculiar artifacts on radiographic images, particularly MRI, due to their ability to produce a high T1 signal, masquerading as pathological findings.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
In this prospective multicenter pilot study, 46 participants were surveyed to assess physicians' knowledge of BTL identification. Demographic data, career length, hair artifact encounters, and identification of artifacts in chest x-rays were collected. Comfort and familiarity with identifying BTLs were reported. ANOVA analysis revealed a significant association between career length and self-reported awareness scores (row factor: [9.8], p < 0.0001). Patient load significantly affected self-reported comfort and familiarity (row factor: [3.1], p = 0.029; p < 0.05).

Conclusion
Although the data obtained are limited, our findings demonstrated that the number of years in practice and the number of patients per day improved physicians’ and technicians' awareness of how Black hairstyles can impact medical imaging. This study presented a radiological phenomenon lacking in literature, as well as provided valuable insights into the impact of experience on physicians' ability to identify and interpret radiographic images affected by hairstyles that can mimic pathology. Further applications of this research may be directed towards comparing pathology localized in lung apices to popular Black hairstyles, assessing the validity of an educational module in increasing awareness and expanding on demographics to explore further associations.