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Danilack VA, Ananth CV. Precision of gestational age for prenatal medication use studies. Paediatr Perinat Epidemiol 2020; 34:607-608. [PMID: 32163183 DOI: 10.1111/ppe.12670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 02/24/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Valery A Danilack
- Division of Research, Women & Infants Hospital, Providence, Rhode Island.,Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Cande V Ananth
- Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey.,Cardiovascular Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey.,Environmental and Occupational Health Sciences Institute, Rutgers Robert Wood Johnson Medical School, Piscataway, New Jersey
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Demirkol ME, Şimşek L, Yılmaz H, Tamam L. Gebelik ve Postpartum Dönemde Obsesif Kompulsif Bozukluk. PSIKIYATRIDE GUNCEL YAKLASIMLAR 2018. [DOI: 10.18863/pgy.336626] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Gentile S, Fusco ML. Placental and fetal effects of antenatal exposure to antidepressants or untreated maternal depression. J Matern Fetal Neonatal Med 2016; 30:1189-1199. [PMID: 27379818 DOI: 10.1080/14767058.2016.1209184] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To assess systematically the effects of antidepressants and untreated maternal depression on human placenta and the developing fetus. METHODS Pertinent medical literature information was identified using MEDLINE/PubMed, SCOPUS and EMBASE. Electronic searches, limited to human studies published in English, provided 21 studies reporting primary data on placental and fetal effects of antidepressant exposure or untreated gestational depression. RESULTS The impact of antidepressants and non-medicated maternal depression on placental functioning and fetal biochemical architecture seems to be demonstrated, although its clinical significance remains unclear. More robust data seem to indicate that exposure to either antidepressants or untreated maternal depression may induce epigenetic changes and interfere with the physiological fetal behavior. Two cases of iatrogenic fetal tachyarrhythmia have also been reported. CONCLUSIONS Future research should clarify the clinical relevance of the impact of antidepressant and untreated maternal depression exposure on placental functioning. Moreover, ultrasound studies investigating fetal responses to antidepressants or maternal depressive symptoms are mandatory. This assessment should be performed during the whole duration of gestational period, when different fetal behavioral patterns become progressively detectable. Analyses of biochemical and epigenetic modifications associated with maternal mood symptoms and antidepressant treatment should also be implemented.
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Affiliation(s)
- Salvatore Gentile
- a ASL Salerno, Department of Mental Health, Mental Health Center Cava de' Tirreni, Vietri sul Mare , Salerno , Italy.,b Department of Neurosciences , Division of Perinatal Psychiatry, Medical School "Federico II", University of Naples , Naples , Italy
| | - Maria Luigia Fusco
- c Mental Health Institute, Torre Annunziata , Naples , Italy , and.,d Department of Developmental Psychology , Post-Graduate School of Psychotherapy (SIPGI), Torre Annunziata, Naples , Italy
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Gentile S. Managing antidepressant treatment in pregnancy and puerperium. Careful with that axe, Eugene. Expert Opin Drug Saf 2015; 14:1011-4. [DOI: 10.1517/14740338.2015.1037273] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Abstract
INTRODUCTION Several concerns have been raised regarding the reproductive safety of the antidepressants most frequently used in clinical practice, such as selective serotonin reuptake inhibitors (SSRIs). AREAS COVERED This article aims to assess the risk/benefit ratio of the use of alternative pharmacological options, specifically tricyclic antidepressants (TCAs) in pregnancy and puerperium. EXPERT OPINION Although TCAs have been prescribed for several decades, their own teratogenic potential to cause structural defects remains undetermined. However, some signals seem to exist suggesting that prenatal clomipramine exposure may increase the risk of cardiac defects. Moreover, TCAs have been associated with the risk of prenatal antidepressant exposure syndrome. Among TCAs, clomipramine seems to be associated with more severe and prolonged neonatal symptoms. However, some findings of this syndrome reported with SSRI use, such as persistent pulmonary hypertension of the newborn, necrotizing enterocolitis and QT prolongation, have not been described after TCA exposure. Hence, current evidence suggests that, as a group, a preference of TCAs over SSRIs in early pregnancy is not justified. In contrast, there appears to be a small gain in safety if TCAs (with the exception of clomipramine) are used in late pregnancy. Among this class of antidepressants, nortriptyline seems to be safest medication for use during breastfeeding.
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Affiliation(s)
- Salvatore Gentile
- Mental Health Center Cava de' Tirreni - Vietri sul Mare, Department of Mental Health, ASL Salerno , Cava de' Tirreni, Piazza Galdi, 841013 Cava de' Tirreni (Salerno) , Italy +39 089 4455439 ; +39 089 4455440 ;
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Sadowski A, Todorow M, Yazdani Brojeni P, Koren G, Nulman I. Pregnancy outcomes following maternal exposure to second-generation antipsychotics given with other psychotropic drugs: a cohort study. BMJ Open 2013; 3:bmjopen-2013-003062. [PMID: 23852139 PMCID: PMC3710985 DOI: 10.1136/bmjopen-2013-003062] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Second-generation antipsychotics (SGAs), in conjunction with other psychotropic medications, are increasingly used to treat psychiatric disorders in pregnancy. The few available studies investigating the reproductive safety of SGAs did not reach conclusive results, and none have compared monotherapy with polytherapy involving other psychotropic medications. DESIGN Descriptive cohort study using a prospectively collected database. SETTING Motherisk Program, The Hospital for Sick Children, Toronto, Canada. PARTICIPANTS 133 women exposed to SGAs and other psychotropic drugs and 133 matched healthy controls were assessed and analysed. Outcomes of mother-child pairs exposed to SGAs in monotherapy (N=37) were compared with those exposed to SGAs with other psychotropic medications (in polytherapy; N=96). MAIN OUTCOME MEASURES Maternal, pregnancy, delivery and neonatal outcomes. RESULTS 72% of exposed women received SGAs in polytherapy, and 101 women took their medications throughout pregnancy. These women had significantly higher pre-pregnancy weight, experienced more associated comorbidities and instrumental deliveries, and delivered a greater proportion of large for gestational age neonates. There were no differences in maternal weight gain in pregnancy between the exposed and comparison groups and between the monotherapy-exposed and polytherapy-exposed subgroups. The exposed neonates were more likely to be born premature, were admitted more often to the neonatal intensive care unit, presented with poor neonatal adaptation signs and had higher rates of congenital malformations. All the aforementioned neonatal outcomes were found mainly in the polytherapy subgroup. CONCLUSIONS The use of SGAs in polytherapy was prevalent in the assessed cohort and was associated with adverse pregnancy outcomes for both the mother and the child. In utero exposure to SGA monotherapy appears to be associated with less risk to the fetus. Future research should focus on polytherapy in pregnancy in order to define its reproductive safety and to separate the effects of medication exposure, underlying psychopathology and associated comorbidities.
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Affiliation(s)
- Alexander Sadowski
- Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Michelle Todorow
- Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, Ontario, Canada
- York University, Toronto, Ontario, Canada
| | - Parvaneh Yazdani Brojeni
- Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Gideon Koren
- Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Irena Nulman
- Motherisk Program, Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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Crowley SK, Youngstedt SD. Efficacy of light therapy for perinatal depression: a review. J Physiol Anthropol 2012; 31:15. [PMID: 22738716 PMCID: PMC3518242 DOI: 10.1186/1880-6805-31-15] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2012] [Accepted: 03/20/2012] [Indexed: 11/13/2022] Open
Abstract
Perinatal depression is an important public health problem affecting 10% to 20% of childbearing women. Perinatal depression is associated with significant morbidity, and has enormous consequences for the wellbeing of the mother and child. During the perinatal period, treatment of depression, which could affect the mother and child during pregnancy and lactation, poses a complex problem for both mother and clinician. Bright light therapy may be an attractive treatment for perinatal depression because it is low cost, home-based, and has a much lower side effect profile than pharmacotherapy. The antidepressant effects of bright light are well established, and there are several rationales for expecting that bright light might also be efficacious for perinatal depression. This review describes these rationales, summarizes the available evidence on the efficacy of bright light therapy for perinatal depression, and discusses future directions for investigation of bright light therapy as a treatment for perinatal depression.
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Affiliation(s)
- Shannon K Crowley
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
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Abstract
A paradoxical drug reaction constitutes an outcome that is opposite from the outcome that would be expected from the drug's known actions. There are three types: 1. A paradoxical response in a condition for which the drug is being explicitly prescribed. 2. Paradoxical precipitation of a condition for which the drug is indicated, when the drug is being used for an alternative indication. 3. Effects that are paradoxical in relation to an aspect of the pharmacology of the drug but unrelated to the usual indication. In bidirectional drug reactions, a drug may produce opposite effects, either in the same or different individuals, the effects usually being different from the expected beneficial effect. Paradoxical and bidirectional drug effects can sometimes be harnessed for benefit; some may be adverse. Such reactions arise in a wide variety of drug classes. Some are common; others are reported in single case reports. Paradoxical effects are often adverse, since they are opposite the direction of the expected effect. They may complicate the assessment of adverse drug reactions, pharmacovigilance, and clinical management. Bidirectional effects may be clinically useful or adverse. From a clinical toxicological perspective, altered pharmacokinetics or pharmacodynamics in overdose may exacerbate paradoxical and bidirectional effects. Certain antidotes have paradoxical attributes, complicating management. Apparent clinical paradoxical or bidirectional effects and reactions ensue when conflicts arise at different levels in self-regulating biological systems, as complexity increases from subcellular components, such as receptors, to cells, tissues, organs, and the whole individual. These may be incompletely understood. Mechanisms of such effects include different actions at the same receptor, owing to changes with time and downstream effects; stereochemical effects; multiple receptor targets with or without associated temporal effects; antibody-mediated reactions; three-dimensional architectural constraints; pharmacokinetic competing compartment effects; disruption and non-linear effects in oscillating systems, systemic overcompensation, and other higher-level feedback mechanisms and feedback response loops at multiple levels. Here we review and provide a compendium of multiple class effects and individual reactions, relevant mechanisms, and specific clinical toxicological considerations of antibiotics, immune modulators, antineoplastic drugs, and cardiovascular, CNS, dermal, endocrine, musculoskeletal, gastrointestinal, haematological, respiratory, and psychotropic agents.
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Affiliation(s)
- Silas W Smith
- Department of Emergency Medicine, New York University School of Medicine, New York, NY 10016, USA.
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Is the exposure to antidepressant drugs in early pregnancy a risk factor for spontaneous abortion? A review of available evidences. ACTA ACUST UNITED AC 2011. [DOI: 10.1017/s1121189x0000052x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
SUMMARYAim– To review studies conducted to establish the risk of spontaneous abortion (SA) in women exposed to anti-depressant drugs (ADs) during early pregnancy.Methods– By using different search terms, PubMed, Toxline, EMBASE, PsychINFO, and the Cochrane library databases were searched from January 1980 to March 2008, to identify studies assessing the risk of SA in women exposed to different classes of ADs during the first trimester of pregnancy.Results– Ten studies over 21 identified were selected for the analysis. All were performed prospectively and included as control group unexposed women, or exposed to non-teratogenic drugs or to placebo. In seven studies a depressive episode was specified as the reason for which the drug was prescribed, while the time of exposure was in nine.Conclusions– Only three studies over ten selected reported a significant association between an increased rate of SAs and early pregnancy exposure to some ADs. Many methodological flaws in the study design were found in all studies considered. Given this background and a lack of strong evidence on this issue, further prospective and better designed studies are needed to assess the risk of SA in pregnant women exposed to ADs against the risk of an untreated maternal depression.Declaration of Interest:None.
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Abstract
PURPOSE OF REVIEW During the last few years, several researches, often showing contradictory findings, have investigated the safety of psychotropic medications used for treating mood disorders in pregnancy. Hence, the necessity exists to update this information constantly in order to ensure the safest option for the mother-infant pair. RECENT FINDINGS The risk of fetal anomalies associated with early in-utero exposure to antidepressants seems to be increased after paroxetine and clorimipramine exposure, whereas prenatal exposure to nearly all antidepressants is linked to the potential onset of the Prenatal Antidepressant Exposure Syndrome. As regards classic mood stabilizers, the teratogenic risk historically reported with lithium should probably be softened, whereas valproate is the medication which shows the strongest association with fetal anomalies. An increased risk of autism-spectrum disorders and infant neurodevelopmental delay is also associated with valproate exposure through the placenta. No significant reproductive safety data are available on atypical antipsychotics, although such medications may indirectly increase the rate of fetal malformation by inducing gestational diabetes. SUMMARY Avoiding the use of clorimipramine, paroxetine, valproate, and atypical antipsychotics during pregnancy is advisable. However, when starting or continuing pharmacological treatment during pregnancy, clinicians should consider not only the intrinsic iatrogenic risk of birth defects or perinatal complications, but also the general safety profile for the expectant mother. Indeed, specific adverse reactions (such as nausea, vomiting, constipation, and excessive weight gain) may aggravate the classic clinical findings of pregnancy, thus indirectly facilitating the occurrence of pregnancy complications and fetal and neonatal problems.
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Jansson LM, DiPietro JA, Elko A, Velez M. Infant autonomic functioning and neonatal abstinence syndrome. Drug Alcohol Depend 2010; 109:198-204. [PMID: 20189732 PMCID: PMC2875284 DOI: 10.1016/j.drugalcdep.2010.01.004] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2009] [Revised: 12/03/2009] [Accepted: 01/12/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Neonatal abstinence syndrome (NAS) expression is widely variable among affected infants and the reasons for this variability are largely unknown; mechanisms that predispose infants to NAS expression are not understood. It has been postulated that the regulatory problems of prenatally drug exposed infants are manifested in dysfunctional vagal regulation of autonomic processes. The current study examines whether cardiac vagal tone, an indicator of parasympathetic neuroregulation, provides a marker for autonomic dysregulation subsequently expressed as NAS in prenatally opioid-exposed newborns. METHODS Heart period (HP) and cardiac vagal tone (V) were derived from electrocardiogram data collected from 64 methadone-exposed infants on postnatal days 1 and 3. The postpartum NAS course was assessed serially. RESULTS Infants with lower V on day 1 had significantly higher NAS symptomatology on day 3. Boys had more severe NAS symptoms than girls through the first 4 days of life and, among infants receiving pharmacologic treatment for NAS, boys required longer treatment course and hospitalizations. Greater poly-drug exposure, detected through toxicology screening throughout pregnancy, and cocaine use in particular, were associated with lower V and shorter HP (faster heart rate) in newborns. Multiple regression models accounted for 25-35% of the variance in NAS symptoms and duration of hospitalization in methadone-exposed infants. Significant predictors included infant sex, SSRI/SNRI use, and cigarette smoking. CONCLUSIONS Results support the hypothesis of a biologic vulnerability of autonomic regulatory functioning in methadone-exposed infants and greater male infant vulnerability to maternal methadone use.
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Affiliation(s)
- Lauren M. Jansson
- Johns Hopkins University School of Medicine, Department of Pediatrics, Baltimore, Maryland, 21224 USA,Corresponding author: Lauren M. Jansson Johns Hopkins University Johns Hopkins Bayview Medical Center The Center for Addiction and Pregnancy 4940 Eastern Avenue, D5 Baltimore, Maryland 21224; USA Telephone: 410-550-5438 Fax: 410-550-2713
| | - Janet A. DiPietro
- Department of Population, Family & Reproductive Health, Johns Hopkins , Bloomberg School of Public Health, Baltimore, Maryland 21224 USA
| | - Andrea Elko
- Johns Hopkins University School of Medicine, Department of Obstetrics and Gynecology, Baltimore, Maryland, 21224 USA
| | - Martha Velez
- Johns Hopkins University School of Medicine, Department of Pediatrics, Baltimore, Maryland, 21224 USA
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On categorizing gestational, birth, and neonatal complications following late pregnancy exposure to antidepressants: the prenatal antidepressant exposure syndrome. CNS Spectr 2010; 15:167-85. [PMID: 20414166 DOI: 10.1017/s1092852900027449] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Late in utero exposure to antidepressants has been suspected of adversely impacting pregnancy outcome and compromising neonatal adaptation. Hence, the necessity exists to analyze published information on antidepressant use during late pregnancy to individuate potential recurrent patterns of iatrogenic complications. METHODS Computerized searches on MEDLINE, PsycINFO, ENBASE, and Cochrane Library through February 10, 2010 were performed for selecting literature information and investigating the safety of antidepressants when used during late pregnancy. RESULTS Antidepressant treatment during late pregnancy may increase the rates of poor pregnancy outcome and neonatal withdrawal/toxic reactions. CONCLUSIONS Because both gestational complications and neonatal adverse events acknowledge the same etiology, the author suggests including such iatrogenic events under the definition of prenatal antidepressant exposure syndrome, in order to increase clinicians' awareness about the spectrum of risks which may concern the mother-infant pair when antidepressant treatment is deemed indispensable during late pregnancy.
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Karpova NN, Lindholm J, Pruunsild P, Timmusk T, Castrén E. Long-lasting behavioural and molecular alterations induced by early postnatal fluoxetine exposure are restored by chronic fluoxetine treatment in adult mice. Eur Neuropsychopharmacol 2009; 19:97-108. [PMID: 18973993 DOI: 10.1016/j.euroneuro.2008.09.002] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Revised: 08/22/2008] [Accepted: 09/09/2008] [Indexed: 01/17/2023]
Abstract
There is evidence that antidepressant drug treatment during a critical period of postnatal development renders mice susceptible to depression- and anxiety-related behaviour in adulthood. The mechanism of how early antidepressant treatment brings about long-term effects in emotional behaviour is not yet understood, but neurotrophins, particularly brain-derived neurotrophic factor (BDNF), have been implicated in this context. We examined the long-term effects of a transient early postnatal fluoxetine treatment on depression- and anxiety-related behaviours as well as gene expression of BDNF and its receptor TrkB in C57BL/6J mice. Treatment with fluoxetine between postnatal days P4 and P21 resulted in a significant loss of body weight and long-lasting behavioural inhibition in adult mice in response to stressful events such as the light-dark or open field tests. Postnatal fluoxetine exposure also decreased behavioural despair in the forced swim test. Both body weight and behavioural alterations were restored by chronic fluoxetine treatment in adulthood. The behavioral alterations were accompanied by changes in hippocampal BDNF mRNA. Specifically, we show that early-life fluoxetine exposure resulted in the long-term upregulation of BDNF expression in adult mice. However, chromatin immunoprecipitation studies did not reveal any changes in the acetylation or trimethylation of histone H3 at the BDNF promoters. Our experiments show that behavioural and molecular changes induced by early postnatal fluoxetine administration are reversed by chronic fluoxetine treatment of adult mice to control levels.
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Affiliation(s)
- Nina N Karpova
- Neuroscience Centre, University of Helsinki, 00014 Helsinki, Finland
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Abstract
INTRODUCTION A growing number of studies have suggested that maternal exposure to post-tricyclic antidepressants during pregnancy might be associated with an increased risk of poor birth, obstetrical, and neonatal outcomes. Among these complications, the occurrence of spontaneous abortions represents one of the most dramatic events for the pregnant woman. METHODS The purpose of this study was to review all studies reporting primary data investigating the rate of spontaneous abortions in women treated with selective serotonin reuptake inhibitors during pregnancy. Medical literature information published in English since 1980 was identified using MEDLINE/PubMed, TOXNET, EMBASE, and The Cochrane Library. Searches were performed using various combination of search terms and were last updated May 2008. No other limitations were imposed. Twelve articles reporting primary data on the rate of spontaneous abortions in women treated with selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors during early pregnancy outcome of pregnancies exposed to antipsychotics were selected for the review. The author was the only reviewer who performed selection and data extraction. RESULTS Information from reviewed studies are scarce and methodologically inadequate to draw definitive conclusions about the hypothesized risk of spontaneous abortions associated with serotoninergic antidepressant exposure during early pregnancy. CONCLUSION Alternative parameters may be considered in choosing the safest serotoninergic antidepressant for the pregnant woman. Such parameters are mainly represented by the teratogenic risk associated with some of such medications and their well-known liability of inducing perinatal complications.
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Gentile S, Vozzi F. Consecutive exposure to lamotrigine and citalopram during pregnancy. Arch Womens Ment Health 2008; 10:299-300. [PMID: 17763980 DOI: 10.1007/s00737-007-0203-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2007] [Accepted: 06/30/2007] [Indexed: 10/22/2022]
Abstract
We describe the case of a pregnancy healthy outcome after in utero consecutive exposure to lamotrigine and citalopram.
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Affiliation(s)
- S Gentile
- Department of Mental Health, Mental Health Center n. 4, ASL Salerno 1, Cava de' Tirreni (Salerno), Italy.
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