Another excellent rebuttal, thank you.
Thank you, and you're welcome.
Fourth, the authors have not corrected for education, insurance status (UHC or private), standing of the neighborhood and general socio-economic status.
As to the highlighted part: isn't that precisely one of the issues that 16.5 had claimed as faulty with the study that was presented earlier that compared (IIRC) Finland with America? Yet it's clearly present in this study. Interesting.
I mainly included it for pestering - you can always try to make objections that there is some other variable at work - but it may indeed have some bearing on the study.
But my last point bears repeating:
Fifth and last: the selection process makes the study utterly worthless. I quote from the paper:
All boys aged 3 years or younger who were not toilet trained and for whom a catheter urine culture had been requested by their treating physician were eligible for inclusion in our study
In other words: this was not a random selection among all the infants in the general area of the hospital; this was a selection among those infants for whom the GP had asked a urine culture, so for whom the GP thought they may have an infection.
Therefore, the paper does not prove that circumcised boys have lower incidence of UTIs. At best, it proves that GPs are more apprehensive about the health of their circumcised patients.
I can't fathom that this paper got through peer review. The selection process of the infants tested totally invalidates the study.
They didn't select random infants. (which would have been the only correct approach, and in that case, a much larger sample had been needed given the rarity of UTIs). Instead, they picked infants that were already referred to the hospital by their GP to be tested for a possible infection. Why did the GP refer them in the first place? There are two possible reasons. The paper, BTW, does not go into the reasons for the GP to refer the infant to the hospital.
1) the GP thought the infant had a health problem and suspected a UTI.
2) for routine screening. No country does routine screening for UTIs: they're rare, especially in males, and they're far from life-threatening, more an annoyance. Canada has a UHC system with the possibility to buy privately supplementary insurance. Those who refer their infant for routine screening for UTI must either have too much money or have a Cadillac supplementary plan. This has a positive correlation with those who circumcise, because that is not covered by the UHC either.
Obviously, the great majority of infants referred to the hospital, and thus included in the study, were referred for reason (1): because the GP thought they had an infection. Therefore, the results of the study don't tell us
anything at all about the incidence of UTI among circumcised vs. uncircumcised, because the obviously healthy infants don't get to the hospital in the first place.
So, the study only tells us about the effectiveness of the GP to successfully refer the patients to the right follow-up procedure. In the case of uncircumcised infants, the GP was right with the test in over 25% of the cases; but in the case of circumcised infants only in 5% of the cases. In other words, circumcision leads to unnecessary tests, and thus wastes UHC funds, i.e., taxpayer money.
The question then is: why do GPs get it wrong more often with circumcised infants than with uncurcumcised? I can think of a number of possible reasons:
a) the referral was not for an acute health problem but for a routine screening - reason (2) above;
b) GPs are more apprehensive about the health of circumcised infants than about uncircumcised;
c) circumcision can give rise to symptoms which seem like those of UTI.
