Brander G, Rydell M, Kuja-Halkola R, et al. Perinatal risk factors in Tourette's and chronic tic disorders: a total population sibling omparison study [Epub ahead of print 2017 Mar 28]. Mol Psychiatry https://doi.org/10.1038/mp.2017.31 The role of perinatal factors in the pathophysiology of Tourette's and chronic tic disorders (TD/CTD) has been repeatedly suggested but never systematically analyzed. The recently published article by Brander and colleagues1 proposes a relationship between the occurrence of TD/CTD and several adverse perinatal events. The study cohort consisted of all live singleton births over a 30-year period in a single country. Follow-up was done over a 40-year period. It included a total of 3,026,861 individuals, 5597 of whom were diagnosed with TD/CTD during the study period. The main results showed that impaired fetal growth, preterm birth, breech presentation, and cesarean section were associated with a higher incidence of TD/CTD. A dose-response relationship also was observed, in which the higher the number of perinatal events, the higher the risk for TD/CTD. Maternal smoking during pregnancy also was suggested to be associated with the risk of TD/CTD in a dose-response manner; however, this could not be verified after sibling comparison analysis. During the current era of continuous genetic cause findings, evidence places TD/CTD among the most heritable, non-Mendelian neuropsychiatric diseases.2 Different studies found high population-based heritability estimates for this disorder3, 4; however, no unique, monogenic cause or ultimate associated risk gene of major effect has been identified, suggesting a polygenic origin for the disease or the possibility that epigenetic factors, such as perinatal hazards, may account for the substantial heterogeneity and complexity of TD/CTD.5 This study is particularly relevant because of its methodological design. It was designed as a population-based study, allowing for exclusion of potential biases and for sibling comparisons and posterior sensitivity analyses to minimize confounders. The first consequence of the study's interesting findings is clinical and relates to the need to address the presence of modifiable risk factors to prevent or reduce the occurrence of TD/CTD. This particular aspect also raises the question of whether these perinatal events are actually risk factors or the result of an ongoing process that generates such events that happen in the perinatal period, considering that impaired fetal growth, preterm birth, breech presentation, and the need for cesarean section can be the result of multiple hazards to the normal fetal development. The second learning point from the study by Brander and coworkers is how relevant epidemiological studies are to help clinicians and researchers clarify controversial hypothesis that arise from results produced by smaller studies or retrospective case series, like those addressing the pathophysiology of TD/CTD. To conclude, this interesting study increases our knowledge about perinatal risk factors for TD/CTD, creates a need for strategies that improve those events during the perinatal period to reduce the occurrence of TC/CTD, and serves as an excellent example of how epidemiological studies with clear and simple designs and analyses can add extremely important information to clinical practice. 1. Research Project: A. Conception, B. Organization, C. Execution; 2. Statistical Analysis: A. Design, B. Execution, C. Review and Critique; 3. Manuscript Preparation: A. Writing the First Draft, B. Review and Critique. V.B.: 1A, 1B, 1C, 3A, 3B J.E.A.: 1A, 1B, 1C, 3A, 3B Ethical Compliance Statement: We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this work is consistent with those guidelines. Funding Sources and Conflict of Interest: The authors report no sources of funding and no conflicts of interest. Financial Disclosures for the previous 12 months: The authors report no sources of funding and no conflicts of interest.
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