Analysis of five sampling methods for the preparation of cervical smears. Papanicolaou smear adequacy: effect of different techniques in specific fertility states. Comparison between Cytobrush and Papaplast in sampling vaginal smears. Ayre v Aylesbury cervical spatulas. Relationship between the diagnosis of epithelial abnormalities and the composition of cervical smears. The influence of sample takers on the cellular composition of cervical smears. The cytological detection of persistent cervical intraepithelial neoplasia after local ablative treatment: a comparison of sampling devices. Quality control measures for cervical cytology laboratories. Efficacy of the cytobrush versus the cotton swab in the collection of endocervical cells. An evaluation of cytologic sampling techniques. A comparative study. Cervical cytology: a randomized comparison of four sampling methods. A randomized trial of three methods of obtaining Papanicolaou smears. The Multispatula; a spatula adjustable to the shape of the individual cervix. The significance of endocervical cells in the diagnosis of cervical epithelial changes. A comparison between the Accu-Pap device and the extended-tip wooden Ayre spatula for cervical cytology sampling. A randomized comparative trial of the performance of the Ayre and the Armovical cervical spatulae. The Cervex: an ectocervical brush sampler. A randomized control trial of two cervical spatulas. Cervical cytology after cryosurgery, laser ablation and conization. A comparison of the cotton swab and endocervical brush. Which cervical sampler? A comparison of four methods. Improved endocervical cell yield with Cytobrush. Sampling accuracy of the modified Ayre spatula/Zelsmyr Cytobrush versus the modified Ayre spatula/bulb aspirator in the collection of cells from the uterine cervix. A randomized comparison of the 3 Papanicolaou smear collection methods. Rates of condyloma and dysplasia in Papanicolaou smears with and without endocervical cells. Cervical smears following laser treatment. Comparison of Cervex brush versus Cytobrush-Ayre spatula sampling. A comparison of four cytological sampling techniques in a genitourinary medicine clinic. Papanicolaou smear adequacy: the effect of the sampling sequence. Evaluation of the endocervical Cytobrush and Cervex-Brush in pregnant women. Endocervical detection of CIN. Cytobrush versus cotton. Detection of abnormal cervical smears. A comparative study. Controlled trial of a new cervical spatula. Simultaneous sampling of the endocervix and ectocervix using the profile brush. A randomized clinical trial comparing the Cytobrush and cotton swab for Papanicolaou smears.
The quality of the cervical smear, a decisive factor in the efficacy of population screening, can depend on the sampling method utilized. An analysis was made of the performance of five sample takers in a screening program, each of whom had made approximately 5,000 smears, and of the five sampling methods each had used: spatula alone (method A), Cytobrush plus spatula (method B), Cytopick (method C), cotton swab plus spatula (method D) and Cervex brush (method E). The differences between the sample takers and the sampling methods were significant in both the detection of grade III cervical intraepithelial neoplasia (CIN III) (P less than .01) and in the production of smears containing endocervical cells (EC+) (P less than .018). The data obtained firmly establish the importance of the presence of endocervical cells for smear adequacy. The results of this study indicate that (1) method B (Cytobrush plus spatula) and method C (Cytopick) give superior results in the preparation of EC+ smears and in the detection of CIN III and thus should be used in population screening programs, and (2) methods A and D should not be used for cervical cytologic sampling in such programs. Six hundred fifty-four Papanicolaou smears were studied prospectively to determine the yield of endocervical cells within specific fertility states by technique used. Smears from postmenopausal women had the lowest yield of endocervical cells (32 percent, P less than 0.01). Smears from postpartum women had a higher yield of endocervical cells than those from pregnant women (69 percent vs 59 percent, P greater than .05). Swabbing excess mucus from the cervix prior to scraping uniformly improved the yield of endocervical cells (70 percent vs 62 percent, P less than .02). In swabbed postmenopausal women, use of a Milex spatula had a significantly higher yield than the use of a wooden spatula and a cotton-tipped applicator (43 percent vs 27 percent, P less than .03). The ability of Cytobrush and Papaplast to collect endocervical cells in vaginal smears was tested in a prospective randomized comparative study including 107 women. Endocervical cells were found more often and in greater numbers with Cytobrush, also in women over 50 years of age. Papaplast missed endocervical cells twice as often as did Cytobrush. The use of the latter instrument meant that the number of repeat smears necessitated due to the absence of endocervical cells could be considerably reduced, with consequent improvement in the cost/benefit ratio. A single blind crossover study compared the traditional Ayre spatula with the new Aylesbury spatula. The study group consisted of all women attending the department of genitourinary medicine during a 16 month period. The same incidence (3.6%) of dyskaryotic smears was found using the Ayre spatula (74/2077) as the Aylesbury spatula (72/2003). The incidence of smears with endocervical cells, however, was significantly greater using the Aylesbury (33.4%) than the Ayre (20.4%) spatulas, despite there being no difference in the incidence of smears with epithelial abnormalities. Quantitative studies thus showed that the Aylesbury gave no more accurate results than the Ayre spatula. The significance of endocervical columnar cells as a high-quality parameter of cervical smears was studied. In a cohort of women with two successive screenings, the consistency of the cellular composition of the cervical smears and the relation between the cellular composition of the smears and the frequency of the diagnosis of abnormal epithelial changes was investigated. At the first screening, a significantly higher number of epithelial abnormalities was found in smears with endocervical columnar cells than in smears without endocervical columnar cells. A significantly higher number of abnormal epithelial changes was found on the second screening in smears from women whose smears from the first screening did not contain endocervical columnar cells than in smears from women whose smears from the first screening did contain endocervical columnar cells. The presence of endocervical cells should be considered a very important indicator of the quality of cervical smears. The chance of missing an abnormal epithelial change is increased in smears without endocervical columnar cells. When endocervical columnar cells are absent, the smear should be considered to be of unreliable quality and a repeat smear should be taken after a short interval, unless the absence of columnar cells can be satisfactorily explained. In a population-based cervical cancer screening program, the performances of five sample takers and their influence on the cellular composition of the smears and the numbers of epithelial abnormalities diagnosed were analyzed. As measured by the presence of endocervical columnar cells, there were remarkable variations in the quality of the smears between sample takers and between years of sampling. There was also a positive relationship between the presence of endocervical columnar cells in the smear and the number of epithelial abnormalities found. A lower quality of smear was reflected by a lower incidence of epithelial atypical changes found, both between sample takers and by a single sample taker over a period of time. These findings show that sample takers influence the cellular composition of smears and, therefore, the diagnostic outcome of smear screening. Their competence in executing their tasks must be frequently reviewed. To determine whether the cytological detection of persistent cervical intraepithelial neoplasia (CIN) after local ablative treatment is improved by the use of sampling devices other than the Ayre's spatula.
                A randomized controlled study.
                Lothian Area Colposcopy Clinic.
                856 patients who had received local therapy (CO2 laser or cold coagulation) for CIN II or III between 9 and 30 months earlier.
                Each patient had three consecutive cervical smears taken, one with the Ayre's spatula, one with either the Aylesbury, the Rocket or the Multispatula device, and finally one with the Cytobrush. The allocation of which spatula and the order of the first two was randomized. Each patient had a colposcopic examination immediately after the smears were taken.
                A comparison of the detection of histologically proven persistent CIN by the Ayre's spatula with the detection of persistent disease by alternative sampling devices.
                Of the 856 patients 130 had histologically proven persistent CIN. Another 98 had suspicious findings on colposcopy but punch biopsies reported as histologically normal. Of the remaining patients with normal colposcopy 130 were randomly selected to form a control group. The cervical smears from these 358 women were reported. Significantly fewer Ayre's samples contained endocervical cells than Aylesbury samples (47% vs 59%, difference 12%; 95% CI 3%-21%; P less than 0.001), Rocket samples (47% vs 67%; difference 20%, 95% CI; 12%-32%; P less than 0.001) or Multispatula samples (47% vs 76%; difference 29%, 95% CI 19-38%; P less than 0.001). When punch biopsies contained CIN, dyskaryotic cells were seen in 10% of Ayre's samples, 4.3% of Aylesbury samples, 8.3% of Rocket samples, and in no smear taken with the Multispatula. Obtaining a third smear with the Cytobrush did not substantially improve the detection rate of dyskaryosis. Neither the order of use of the spatulas, the form of initial treatment nor the size of the transformation zone had any apparent effect on the cytological detection of persistent CIN.
                We recommend that surveillance of patients who have received local ablative therapy for CIN should be by both cytology and colposcopy, and that cytological samples should be obtained using the Ayre's spatula. The results of three quality control measures for evaluating a cytopathology laboratory's performance in the diagnosis of cervical abnormalities are presented. The sensitivities of cervical cytology were estimated to be 95.5% or 93.1% (using two different methods of analysis) for the detection of histologically diagnosed invasive squamous cell carcinoma of the cervix and 60% for the detection of adenocarcinoma and adenosquamous carcinoma of the cervix in 1983. The positive predictive values for a histologic diagnosis of neoplasia after cytologic reports of CIN III and invasive carcinoma were 92.5% and 99%, respectively. Repeatability of a negative cytologic result exceeded 98%. These results indicate that accurate cervical cytologic reporting can be achieved. Regular monitoring of the type described, which is both practical and reasonably comprehensive, is recommended for all laboratories. Cervical smears should contain endocervical cells to be accepted as adequate for a cytologic diagnosis. Before this study was undertaken, one-third of the smears received in the Cytology Laboratory of Odense University Hospital were inadequate. In an attempt to increase the rate of adequate smears, a randomized study was undertaken to compare the efficacy of the combined spatula-Cytobrush method to that of the spatula-cotton swab method traditionally used by doctors in Denmark. The incidence of smears containing cylindrical and/or metaplastic cells was 89% by the spatula-Cytobrush method as compared to 62% by the spatula-cotton swab method (P less than .001). There were large differences between the rates of adequate smears from the various doctors when using the spatula-cotton swab method (range, 14% to 82%); these differences were far less when using the spatula-Cytobrush method (range, 75% to 100%). A large-scale application of the spatula-Cytobrush method should result in fewer repeat smears required and fewer false-negative smears. False negative cervical cytology is primarily due to errors in sampling. It has been demonstrated that combined ectocervical and endocervical sampling techniques will improve the yield. A prospective study was done to compare ectocervical and combined sampling with a selective technique in which the examiner determines the location of the squamocolumnar junction and chooses the appropriate method. The results demonstrate that combined ectocervical and endocervical sampling significantly increases the number of positive Papanicolaou smears. Selecting which cervices should be samples ectocervically and which need combined sampling does not significantly improve the yield over ectocervical sampling alone. It is the conclusion of this study that both ectocervical and endocervical sampling should routinely be used. The purpose of this study was to compare smear quality and endocervical cell recovery of four cervical smear sampling devices.
                Two thousand fifteen patients undergoing routine cervical smears at the University of Tennessee Obstetrics and Gynecology clinics were randomly assigned to a cotton swab-spatula, Cytobrush-spatula, Cervex-Brush, or Bayne Pap Brush. The cytopathology laboratory, blind to method, used specific criteria to grade smears as being optimal, adequate, marginal, or inadequate. Statistical analysis was by the chi 2 and analysis of variance tests.
                No statistical differences occurred among the groups for nonpregnant patients. For pregnant patients smear quality was improved with both Cytobrush-spatula and Bayne Pap Brush versus cotton swab-spatula (p = 0.0301 and 0.0004, respectively); cotton swab-spatula had fewer endocervical cells than the Cytobrush-spatula (p = 0.0001), Cervex-Brush (p = 0.0288), and Bayne Pap Brush (p = 0.0081).
                The cotton swab-spatula and Cytobrush-spatula appear to be the most effective screening methods for nonpregnant and pregnant patients, respectively. The relationship between technique of obtaining Papanicolaou smears, presence of endocervical cells, and rate of cervical neoplasia was studied by comparing an endocervical and ectocervical nylon brush (Bayne brush), Ayre spatula plus endocervical brush, and spatula plus cotton-tipped swab in a randomized, prospective trial involving 11,061 patients. Eligible patients had a cervix and were not pregnant. Clinic records of patients with abnormal cytology were reviewed to determine the pathologic diagnosis. Whether pathology was defined as including condyloma, dysplasia, and cancer; dysplasia and cancer; moderate dysplasia, severe dysplasia, and cancer; or just severe dysplasia and cancer, no significant difference was found in the rates of pathology between the three techniques. Endocervical cells were identified in 89.5% of smears obtained with the Bayne brush, in 91.5% with the spatula plus endocervical brush, and in 71.1% with the spatula plus cotton-tipped swab (P less than .001). Among smears obtained with the spatula plus swab, the rate of any pathology was higher in smears that contained endocervical cells than in smears in which endocervical cells were absent (2.0 versus 0.6%; P = .009). After correction for the influence of age, there remained predictive value with the presence of endocervical cells. Once corrected for the influence of age, the rate of pathology and abnormal cytology in smears obtained with the spatula plus brush or the Bayne brush was not dependent upon the presence of endocervical cells.(ABSTRACT TRUNCATED AT 250 WORDS) The Multispatula, which is adjustable to the specific shape of each individual cervix, was compared with the Ayre spatula in 236 patients. Two smears were taken from each woman, one with the Ayre and one with the Multispatula. The Multispatula had a significantly higher percentage of smears containing endocervical cells than the Ayre spatula. Disadvantages of the Multispatula are its high price and the sharp edges causing somewhat more pain and bleeding. There were major differences in the quality of the smears between the various sample takers. A study was made of the relationship of endocervical columnar cells to the cytologic identification of abnormality in the cervix. From a population of women participating in a cervical cancer screening program, a group of women was selected whose smears theoretically should have contained endocervical columnar cells. Endocervical cells were present in 93.1% of the smears and absent in 6.9%. A significantly higher number of moderately and severely atypical epithelial changes was found in smears with endocervical cells as compared with smears without endocervical cells. The wooden Ayre spatula with an extended endocervical tip was compared with both designs of the plastic Accu-Pap sampler in two series of 100 consecutive patients to compare their adequacy in obtaining samples for cervical cytology. There was no significant advantage noted in the smears taken by either spatula. In terms of the sequence of smears, the second smear generally contained more endocervical cells and less often showed an absence of diagnostic cells. The Ayre and the Armovical cervical spatulae were compared in a randomized trial involving 982 women of childbearing age. It was found that the Armovical spatula was slightly less effective than the Ayre spatula in obtaining adequate numbers of squamous cells. The Armovical spatula was, however, far better at providing a sample of endocervical or metaplastic cells and, as a result, yielded a substantially higher proportion of 'satisfactory' smears (54 per cent as against 39 per cent). Red blood cells were more often present in smears taken with the Armovical spatula than with the Ayre spatula. Although the data in the present study were too few to prove that the Armovical spatula is better than the Ayre spatula at detecting cellular abnormalities, it seems likely that this is so. The performance of a new ectocervical brush sampler--the Cervex--was compared with the Ayre spatula in 280 paired cervical smears. The Cervex smears were superior in quality of spread, transformation zone sampling in all degrees of cervical patency and in detection of histologically proven epithelial abnormalities, with a false negative rate of 10.9% compared with 20% for the Ayre. Improvement in predictive value was noted in atrophic samples, with increased cellularity and transformation zone representation. Difficulty has been encountered in obtaining adequate samples from the older woman and from those with iatrogenic scarring of the cervix. Although two-sampler techniques may be used, submission of high quality pan-cervical material from a single sampler onto one slide is economically and organizationally attractive. The Cervex seems capable of producing such samples and deserves further evaluation for routine screening. The sampling efficacy of the Ayre and Rocket cervical spatulas was compared in a randomized controlled trial involving 533 women who were attending a colposcopy clinic either for investigation of cytological abnormality or for review after treatment of CIN. Smears were compared with respect to the presence of cytological abnormality and two types of normal cervical epithelial cells (endocervical and immature metaplastic cells) which are considered indicators of adequate cytological sampling. Smears taken with the Rocket spatula were significantly less likely to contain immature metaplastic cells (95% CI on difference in proportion; 5-30%), but more likely to contain endocervical cells (95% CI 16-36%). No significant difference was found in the proportion of smears containing one or other type of indicator cell or in the yield of abnormal smears. It is concluded that the Rocket spatula offered no advantage when used in these circumstances. This study illustrates how spurious conclusions of sampling efficacy can be drawn if only one type of indicator cell is used as an endpoint. Obtaining an adequate Papanicolaou smear, as evidenced by the presence of endocervical cells, is paramount in following patients after treatment for cervical dysplasia. A randomized, prospective trial was done in which 203 patients with a history of cryosurgery, laser ablation or cone biopsy were randomized into two groups: 114 patients had cervical smears done with a cotton swab and 89 patients with an endocervical brush. The presence or absence of endocervical cells was noted on the cytology report. Overall, the endocervical brush produced significantly more adequate smears than did the cotton swab (86% vs. 74%, P = .0389). Within each subgroup the endocervical brush consistently produced a higher number of adequate smears than did the cotton swab: after cryosurgery, 86% vs. 82%, P = .7242; after laser ablation, 95% vs. 88%, P = .61; after conization, 76% vs. 47%, P = .0675. The difference was most notable in the conization group. The endocervical brush is superior to the cotton swab in obtaining satisfactory Papanicolaou smears after cryosurgery, laser ablation and conization. Four cytology sampling methods were compared in 1063 patients referred for colposcopy with a recent abnormal smear. A dyskaryotic smear of any grade was considered a positive result, though comparisons were limited to cases with a subsequent biopsy confirming CINII or III. There were no differences between the abilities of any of the four methods to detect higher grades of CIN (chi (2)3 = 4.603, P > 0.20). The presence or absence of endocervical cells in a smear was not significantly associated with any variation in success rate (chi (2)1 = 0.959, P > 0.30). The joint analysis of the four methods and the presence/absence of endocervical cells also showed no significant effects (chi (2)7 = 12.768, 0.1 > P > 0.05). In the latter analysis the trend towards a conventional level of significance was accounted for by the Aylesbury spatula giving a relatively high success rate when endocervical cells were present. The suggestion of advantage for the Aylesbury spatula merits further investigation. A prospective study of 402 Papanicolaou smears was done comparing the effectiveness of three techniques in obtaining endocervical cells. The Zelsmyr Cytobrush cell collector yielded the greatest concentration of endocervical cells. More than one half (53.6 percent) of all cell samples obtained with the Zelsmyr Cytobrush produced "moderate" or "large" concentrations. The extended-tip spatula and cotton-tip swab techniques produced only 38.5 percent and 24.2 percent, respectively, in these categories. The Zelsmyr Cytobrush cell collector is an effective instrument, yielding increased numbers of endocervical cells on Papanicolaou smear. An 8-mo (August 1988 through April 1989) study was performed to evaluate the efficacy of the modified Ayre spatula/Zelsmyr Cytobrush versus the modified Ayre spatula/bulb aspirator in the collection of cells, both normal and abnormal, from the uterine cervix. The majority (78%) of the 192 patients, ranging in age from 18 to 82 yr, were referred to the gynecologic/oncologic clinic for follow-up of an atypical Papanicolaou smear or of a previously diagnosed and treated cervical, vulvar, or endometrial lesion. Of the 192 patients, 149 were premenopausal (15 of whom were pregnant), 12 were perimenopausal, and 31 were postmenopausal. Patients were randomized into one of two groups based on the collection of samples for their cervical smears: 1) modified Ayre spatula (exocervix) plus Zelsmyr Cytobrush (endocervix: 90 cases) and 2) modified Ayre spatula (exocervic) plus bulb aspirator (endocervix; 102 cases). Of the smears prepared with the spatula/Cytobrush (90 cases), only 2 (2.2%) lacked endocervical cells. Within this group, the smears of 5 of 5 pregnant patients (100%) and 13 of 13 postmenopausal patients (100%) contained endocervical cells. Cytologic abnormalities were present in 15 of these cases; koilocytosis in 4, cervical intraepithelial neoplasia (CIN)-I in 5, CIN-II in 4, and CIN-III in 2. Five of the 15 cytologically positive cases had histologic verification; the cytologic findings were predictive of the histologic findings in all. Of the smears prepared using the spatula/bulb aspirator (102 cases), 26 (25.5%) lacked endocervical cells. Within this group, the smears of only 4 of 10 pregnant patients (40%) and 14 of 18 postmenopausal patients (78%) contained endocervical cells.(ABSTRACT TRUNCATED AT 250 WORDS) The purpose of this study was to compare the effectiveness of 3 cervical smear sampling devices for obtaining acceptable yields of endocervical cells in Papanicolaou smears. In a randomized, controlled clinical trial, we collected 346 smears over a 6-month period, 110 with the Cervex brush, 125 with the cotton swab plus Ayre spatula and 111 with the Cytobrush plus Ayre spatula. The Cytopathology Laboratory, blinded to the Papanicolaou smear method, screened the smears using the Bethesda system guidelines. Statistical analyses were performed using the Pearson X2 and analysis of variance tests. There was an increased detection of endocervical cells in the Cytobrush plus Ayre spatula and the Cervex brush methods, compared with the cotton swab plus Ayre spatula group (p = 2.39 x 10(-6), p = 4.49 x 10(-7) respectively). There was no statistically significant difference between the Cytobrush-Ayre spatula and the Cervex brush sampling methods were equally effective in obtaining endocervical cells in Papanicolaou smears. A retrospective study of 36,853 Papanicolaou smears recorded in our laboratory during the latter half of 1988 was undertaken to assess the effect of the absence or presence of columnar endocervical cells on the detection rate of cervical condyloma acuminatum and squamous dysplasia. We found that condyloma was diagnosed only slightly more frequently in smears with endocervical cells than in those without. However, cervical intraepithelial neoplasia was detected 2.3 times more frequently in smears with endocervical cells. The disparity in detection rate increased with higher grades of dysplasia. A significant difference in detection rate was maintained in all age groups except teenagers and patients 60 yr old and above. This suggests that smears lacking endocervical cells are less sensitive in screening for dysplasia and should be repeated when clinically appropriate. For 802 women at initial follow-up after laser treatment of cervical lesions, 421 smears prepared using the Cervex brush were compared with 381 smears prepared using the combination of a Cytobrush plus an Ayre spatula. The smears were graded for adequacy, the presence of endocervical or metaplastic cells and the presence and degree of epithelial abnormalities. Endocervical or metaplastic cells were seen more often in Cytobrush-Ayre spatula smears (94.5%) as compared with Cervex brush smears (88.8%; P = .004). Also, the number of samples classed as inadequate was significantly greater with Cervex brush smears (4.0%) than with Cytobrush-Ayre spatula smears (0.3%; P = .0003). The number of smears showing dysplasia was too small to detect realistic differences between the two sampling methods. These findings suggest that, in women who have had laser treatment of the cervix, Cytobrush plus Ayre spatula sampling produces better-quality smears than does Cervex brush sampling, with regard to both adequacy and the presence of endocervical cells. Four cytological sampling techniques (the Ayre's spatula alone, the Ayelesbury spatula, the Ayre's spatula in conjunction with a Cytobrush (Medscand), and the Cervex (Steriseal] were compared when used in a genitourinary medicine clinic. Over a period of two years 6991 smears were taken. No difference was found between the methods with regard to detection of dyskaryosis, although there were significant differences in the percentage of smears containing endocervical cells. The purpose of this study was to determine the effect of ectocervical sampling methods and sequence on Papanicolaou smear adequacy.
                A randomized clinical trial was performed using either a curved cytologic sampling brush or Ayre spatula for ectocervical sampling before or after a straight sampling brush for endocervical sampling.
                The adequacy of ectocervical smears, as measured by the presence of columnar cells or squamous metaplasia, differed significantly among the four techniques studied. When the Ayre spatula was used second, 115 (69 percent) of 167 ectocervical smears were adequate compared with 75 (48 percent) of 156 smears when it was used first. Likewise, when the curved brush was used second, 116 (67 percent) of 172 ectocervical smears were adequate compared with 80 (50 percent) of 160 smears when it was used first. One hundred ninety-six (59 percent) of 332 ectocervical smears obtained with a curved brush were adequate compared with 190 (59 percent) of 323 ectocervical smears obtained with a spatula.
                The differences among the four ectocervical sampling techniques studied were due to the sequence of ectocervical sampling rather than the instrument utilized. We recommend that an ectocervical sample be obtained only after a straight brush is used to obtain an endocervical sample. To compare, in pregnant women, the endocervical cell yield of the Cytobrush Cell Collector and the Cervex-Brush Cell Sampler with the standard cotton swab, and to determine the incidence of serious adverse events associated with the collection techniques.
                In a randomized, controlled clinical trial, 352 pregnant women undergoing initial obstetric evaluation were randomly assigned to either the cotton swab and modified Ayers spatula, Cytobrush and modified Ayers spatula, or Cervex-Brush. The cytopathology laboratory, blinded to the Papanicolaou smear method, screened the smears using the Bethesda System guidelines. Statistical analyses were performed using the Pearson chi 2 and analysis of variance tests.
                There was an increased detection of endocervical cells in pregnant patients with both the Cytobrush and modified Ayers spatula (90.7%) and the Cervex-Brush (83.3%) methods, compared with the cotton swab and modified Ayers spatula (70.8%) (P = .0001 and P = .0233, respectively). There was no statistically significant difference between the Cytobrush-spatula and Cervex-Brush groups (P = .0956). Although there were more bloody Papanicolaou smears in the study groups, this was neither clinically nor statistically significant because all the samples were interpretable and repeat samples due to bloody specimens were not required. There were no serious adverse events associated with the study group methods.
                Performance of Papanicolaou smears using the Cytobrush and modified Ayers spatula and with the Cervex-Brush improved Papanicolaou smear adequacy as compared with the cotton swab and modified Ayers spatula. Despite an increased incidence of spotting following collection, these techniques were not associated with an increase in serious adverse events. Based on the cost per item and a clinically significant increase in endocervical cell yield, we recommend the Cytobrush and modified Ayers spatula for cytologic screening in pregnant women. Correct methods of sampling are essential for obtaining adequate smears for cytological diagnosis of cervicovaginal abnormalities. In this paper we report on 3 methods of sampling, Ayre spatula, cotton swab and cytobrush on 89 patients who underwent repeat smear and colposcopic examinations because of abnormal screening smears. The cytobrush device was better than Ayre spatula or cotton in collecting both endocervical and neoplastic cells. However, the combination of spatula and cotton was almost the same as spatula and cytobrush in recovering neoplastic cells. Therefore the rate of cervical intraepithelial neoplasia (CIN) diagnosis is more influenced by an adequate sampling of the endocervix than by the type of endocervical device. The inefficiency of the Ayres Spatula in detecting abnormality in cervical cytology has been demonstrated recently in a number of trials. In a randomized single-blind trial we have compared the Multispatula with the Ayres Spatula in a group of 158 women who previously had abnormal smears and had been referred to colposcopy clinics in the Lewisham and North Southwark Health Authority of London. The quality of the smears, as assessed by the presence or absence of endocervical cells, revealed that the Multispatula (87.3% pick-up) produced significantly better smears (p less than 0.005) compared with the Ayres Spatula (54.4% pick-up). In 149 smears collected with the Multispatula, atypia was confirmed. However, in only 129 smears taken with the Ayres Spatula were abnormal smears detected (p decreases less than 0.005). We concluded that the Multispatula produces a better quality smear which results in a decreased false negative rate in comparison with the Ayres Spatula. A wooden spatula was designed to scrape the varied distribution of epithelial abnormalities of the cervix as seen at colposcopy. The efficiency of the spatula in obtaining dyskaryotic cells and improving the cellular quality of smears was compared with that of the Ayre spatula in a controlled trial. More than 17,000 smears were taken from women aged 14-86 years by more than 200 smear takers from 74 centres. Twenty two per cent more dyskaryotic smears were obtained with the trial spatula, and the cellular quality of the smears was improved in all age groups. Although it was associated with a slightly increased risk of bleeding, 83% of users preferred the trial spatula. In a controlled trial a new modified nylon brush (Profile brush) was compared for endocervical cell pickup with the combination of an Ayre spatula and traditional cytobrush. The two devices produced the same endocervical cell pickup rates (Ayre + cytobrush, 82.0%; Profile, 82.7%). The smears were of good quality, with no difference in the incidence of scanty or unsatisfactory smears. The Profile brush was easy to use. It may be an alternative to the combination of an Ayre spatula and cytobrush for sampling the cervix. We sought to determine whether use of the Cytobrush/spatula or the cotton swab/spatula is better in obtaining satisfactory Papanicolaou smears as defined by the Bethesda System.
                This 1-year randomized trial was performed at the Los Angeles County + University of Southern California Women's Hospital colposcopy clinic. Participants were all nonpregnant patients referred to the colposcopy clinic for abnormal Papanicolaou smears. The main outcome measurement was the effectiveness in obtaining satisfactory Papanicolaou smears as defined by the Bethesda System. Data were analyzed using the Pearson chi 2 test.
                The sampling methods had similar abilities to obtain a satisfactory smear (Cytobrush/spatula 63%, cotton swab/spatula 57%; P = .23). Less-than-optimal smears accounted for 28% of the Cytobrush group and 38% of the cotton-swab group. The Cytobrush was superior in its ability to obtain endocervical cells (Cytobrush 80%, cotton swab 60%; P less than .01). Both sampling methods had similar rates of correlation with histologic diagnosis. No complications were associated with either technique.
                The Cytobrush/spatula is superior to the cotton swab/spatula in obtaining endocervical cells. There appears to be no difference in each method's ability to obtain satisfactory smears. Application of the Bethesda System results in a significant number of less-than-optimal smears using either technique.