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INTEGRATED CARDIOLOGY DIVISION Director: Prof. Gianfranco Sinagra
CARDIOLOGY DIVISION
Director: Prof. Gianfranco Sinagra Cattinara Hospital - Cardiology Complex – Via Valdoni 7
Tel: 040 399 4477 e-mail: [email protected]
NURSING COORDINATORS:
Ward: Daria Beltrame Tel: 040 399 4851; Fax: 040 399 4003
e-mail: [email protected]
Coronary Unit: Tiziana Canderlic Tel: 040 399 4646; Fax: 040 399 4491
e-mail: [email protected]
Hemodynamics and Invasive Cardiology Room: Cinzia d i Chiara Tel: 040 399 4865; Fax: 040 399 4878
e-mail: [email protected]
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USEFUL TELEPHONE NUMBERS FAX OUTPATIENTS’ DEPARTMENT Ground Floor
040 – 399 4865 040 – 399 4878
8 a.m. – 3 p.m, Monday to Friday
WARD ADMINISTRATION Second Floor
040 – 399 4875 040 - 399 4003
8 a.m. – 3 p.m., Monday to Friday
WARD 040-399 4871 040 – 399 4003
CORONARY UNIT Third Floor
040 – 399 4877 040 – 399 4491
Always operational, 7 days a week, 24 hours a day
DIAGNOSTIC AND INVASIVE HEMODYNAMICS Third Floor
040 – 399 4875 040 – 399 4988
8 a.m. – 3 p.m., Monday to Friday
ELECTROPHYSIOLOGY AND ELECTROSTIMULATION Third Floor
040 – 399 4828 040 – 399 4491
8.30 a.m. – 3 p.m., Monday to Friday
CARDIAC ULTRASOUND Ground Floor
040 – 399 4837
8.30 a.m. – 3 p.m., Monday to Saturday
Arrhythmia and Pacemaker Clinic Ground Floor
040 – 399 4828
040 – 399 4878
8.30 a.m. – 3 p.m., Monday to Friday
Cardiomyopathy and Heart Failure Clinic Ground Floor
040 – 399 4125 040 – 399 4878
8 a.m. – 3 p.m., Monday to Friday
CARDIOLOGY UNIT (Ospedale Maggiore)
040 – 399 2248 040 – 399 2298
8 a.m. – 3 p.m., Monday to Friday
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TABLE OF CONTENTS Medical Staff Page 8
Our Mission Page 9
Our Motto Page 9
Presentation Page 10
What to bring to hospital Page 11
Location: how to find us Page 12
Visiting hours Page 13
Interviews with relatives Page 13
Coronary Unit Page 14
Diagnostic and Invasive Hemodynamics Page 16
Electrophysiology and Electrostimulation Page 18
Cardiology Ward Page 19
Cardiac Ultrasound Page 22
Electrocardiography Page 23
High-resolution and Holter Electrocardiography Page 24
Ergometry and tilt tests Page 25
Divisional Outpatients’ Service Page 26
Pacemaker and Defibrillator Clinic Page 27
Clinics for Cardiomyopathy and Heart Failure, Pulmonary Hypertension, Complex Angioplasties and Percutaneous Aortic Prostheses, Percutaneous Treatment of Congenital Defects
Page 28
Diagnostic and Invasive Electrophysiology and Arrhythmia Clinic
Page 29
Cardiology Unit of Ospedale Maggiore and Cardiac Rehabilitation
Page 31
Computerization
Page 34
Admission to the Cardiology Division Page 35
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Treatments and average waiting times Page 35
Pain control Page 36
Informed consent Page 36
Patients’ involvement in their treatment Page 37
How to distinguish staff by uniform colour Page 39
Religion Page 40
Information for patients Page 40
Cultural mediation Page 41
Visits Page 41
Patient safety Page 42
Mobile phones Page 43
Food Page 43
Recommended diet for cardiac patients
Page 44
Drugs Page 47
Cash and valuables Page 47
Rules of conduct Page 47
Certificate of admission Page 48
Complaints procedure Page 48
Discharge from hospital Page 48
Acute cases Page 50
How to request patients’ medical files Page 50
Continuity of care Page 51
Organisation, communication, training and quality control
Page 52
Research and scientific activities Page 54
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The Cardiology unit seen from the Via Valdoni entrance. It can also be reached by following the signs through an internal link from Cattinara
Hospital.
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MEDICAL STAFF Ward
Dr. Gerardina Lardieri Dr. Lorena Barbieri Dr. Francesca Brun Dr. Renata Korcova Dr. Laura Massa Dr. Marco Merlo Dr. Michele Moretti Dr. Alberto Pivetta
Diagnostic and Invasive Hemodynamics
Dr. Alessandro Salvi Dr. Andrea Perkan Dr. Serena Rakar Dr. Giancarlo Vitrella
Cardiology Intensive Care Unit
Dr. Marco Milo Dr. Francesco Lo Giudice Dr. Annamaria Sorrentino Dr. Irena Tavcar
Non-invasive Diagnostics and Cardiac Ultrasound
Dr. Elena Abate Dr. Bruno Pinamonti Dr. Gabriele Secoli
Electrophysiology, Arrhythmology and Electrostimula tion
Dr. Massimo Zecchin Dr. Fulvia Longaro Dr. Luca Salvatore Dr. Laura Vitali Serdoz
Cardiology Unit of Ospedale Maggiore and Cardiac Rehabilitation
Dr. Patrizia Maras
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OUR MISSION TO MEET PATIENTS' NEEDS BY OFFERING INDIVIDUAL
ATTENTION AND AN EXCELLENT SERVICE
OUR MOTTO
1) THE PATIENT IS OUR PRIORITY
2) FOCUS ON TOTAL QUALITY AND EFFICIENCY
3) LISTENING TO, ACTIVELY INVOLVING AND
COMMUNICATING WITH THE PATIENT.
CONSTANT DEVELOPMENT OF OUR THINKING,
ORGANISATION, TECHNOLOGIES AND
TRAINING
4) SUSTAINABLE DECISIONS
5) “ME” AS PART OF THE “SYSTEM”
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Dear Sir/Madam,
In welcoming you to our Division we would like to give you some
information that will help improve your stay in this hospital. Our staff
will be able to explain our services to you.
If one of your relatives is admitted to the Cardiology Division, this
brief presentation may be useful to you. Getting to know the hospital
will help you to deal with the situation better.
PRESENTATION
The Cardiology Division of the Trieste University Hospital Authority
was established in 1967, at Ospedale Maggiore, led by Prof. Fulvio
Camerini.
Since 1999, the division has been run by Prof. Gianfranco Sinagra.
In May 2003 it moved to the Cardiology Complex at Cattinara
Hospital, while Ospedale Maggiore maintained its Cardiology
Consulting, Non-Invasive Diagnostics and Cardiopathic
Rehabilitation Unit. It is home to Trieste University’s School of
Specialization of Diseases of the Cardiovascular System, and also
hosts many courses and traineeships related to undergraduate and
postgraduate degrees, and national and international professional
development programmes.
The working group is formed of doctors, coordinators, nurses, public
health workers, experts in cardiac pathophysiology, physiotherapists
and administration staff.
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WHAT TO BRING TO HOSPITAL
Personal documents :
E.C. CITIZENS:
ID document
Health card issued by the local health authority
Tax code
Admission proposal form
FOREIGN NATIONALS NOT REGISTERED WITH THE
ITALIAN NATIONAL HEALTH SERVICE AND NOT RESIDENT
IN ITALY:
passport and/or ID card, ISI form and/or permit of stay.
Clinical documentation :
Diagnostic tests, clinical records, documentation
concerning medical history and current treatment.
If the drugs you are taking are not available in our
division, at the time of admission you are asked to hand
your drugs to the doctors or nursing staff who will check
that they are intact and have not expired before
administering them as you are used to doing at home.
Personal effects :
Underwear, dressing gown and slippers, towels.
Everyday toiletries.
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HOW TO FIND US
Cattinara Hospital
Cardiology Complex, Via P. Valdoni, 7 CAP 34149, Trieste.
Outpatients’ department and non-invasive diagnostic
testing (cardiac ultrasound, electrocardiography, ergometry,
Holter ECG and tilt tests), Ground Floor
Cardiology ward 2nd floor
Coronary and Cardiology Intensive Care Unit , 3rd floor
Diagnostic and Invasive Hemodynamics, 3rd floor
Electrophysiology and Electrostimulation , 3rd floor
Ospedale Maggiore
Via Pietà 2/2 (Distretto) 1st floor, 34134, Trieste
Cardiology Unit and Cardiac Rehabilitation
.
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VISITING HOURS
WARD Monday-Saturday 6 p.m. - 8 p.m.
Sundays and holidays
12.30 - 2.30 p.m.
6 p.m. - 8 p.m.
CORONARY UNIT Monday-Saturday 6 p.m. - 7 p.m.
Sundays and holidays
12 noon - 1 p.m.
6 p.m. - 7 p.m.
As this is an intensive care division, YOU ARE KINDLY ASKED TO
RESPECT THE ABOVE HOURS in order to provide your relatives
with the best possible care, and to allow our staff to carry out their
duties.
NTERVIEWS WITH RELATIVES
Please refer to the indications outside the room of the doctor
treating the patient.
WARD Monday, Tuesday, Thursday, Friday: 3–4 p.m. (contact the ward administration office to request an appointment with a doctor)
CORONARY UNIT Monday to Friday: 12.30 – 1.30 p.m. and 6 p.m. - 7 p.m.
On public holidays, and in the days beforehand, essential information can be obtained from the doctor on duty, who can be contacted through the nursing staff in each section.
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CORONARY UNIT
Location: 3rd Floor, Cardiology Complex, Cattinara Hospital.
Director: Dr. M. Milo
At least 1 doctor is always present, 24 hours a day , 7 days a
week.
The Coronary Unit has 6 intensive care beds, 2 isolation beds and 2
semi-intensive beds, divided into rooms with 1 or 2 beds each. It
accommodates critically-ill patients requiring intensive monitoring.
The unit admits around 1000 patients each year, suffering from:
Acute Myocardial Infarction – STEMI, 30%,
Acute Coronary Syndrome – NSTEMI, 40%,
Acute Heart Failure, 15%,
Life-threatening Arrhythmias, 10%,
Massive Pulmonary Embolism, 2%,
Aortic Dissection and Cardiac Tamponade, 5%.
The Coronary Unit offers advanced intensive care by means of
invasive hemodynamic monitoring, aortic counterpulsation,
ultrafiltration and hemodialysis, and invasive mechanical ventilation.
It is the landmark centre for the Isontino-Giuliana region (30% of
patients are not resident in the province).
Medical and nursing activities are organised on a 24-hour basis, and
all staff have basic life support defibrillation (BLSD) certification,
while the doctors have Advanced Cardiac Life Support (ACLS)
certification. All clinical and organisational activities are governed by
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periodically updated protocols, procedure and guidelines which can
easily be accessed.
The division provides consulting services for General Critical Care
(Anesthesia, Resuscitation and Pain Relief), and the Emergency
Ward. Many of the clinical cases shared with these two departments
are governed by approved protocols (a hypothermia protocol for
patients surviving cardiac arrest, a protocol for the management of
chest pain and arrhythmic patients in the Emergency Ward).
The division has a long tradition of involvement in controlled clinical
studies and observational registers.
Our Coronary and Cardiology Intensive Care Unit has also been
accredited according to the operating standards of the European
Society of Cardiology (ESC).
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DIAGNOSTIC AND INVASIVE HEMODYNAMICS
Location: 3rd Floor, Cardiology Complex, Cattinara Hospital
Director: Dr. A. Salvi
The Diagnostic and Invasive Hemodynamics Section, mainly
dedicated to patients admitted to the Trieste Cardiology Division, is a
regional landmark for diagnostics and mini-invasive procedures
using catheters which are inserted beneath the skin and guided
along the artery to the heart.
Every year, more than 2,000 procedures are carried out, including
more than 600 percutaneous cardiology operations.
These procedures are conducted in the Hemodynamics Room and
consist of coronarographies, cardiac catheterization,
ventricolography, cardiac and artery biopsies, and most importantly
of balloon-assisted procedures for dilatation and the placement of
stents on the coronary and other arteries. This room is also where
aortic valve prostheses are fitted, as well as procedures for the
percutaneous closure of congenital defects (foramen ovale and heart
defects which cause shunting).
Both the radial and femoral approaches are used for these
procedures.
Two modern hemodynamics rooms have been set up for these
treatments, specifically designed for cardiovascular use. Both rooms
are fully digitalised and can also be used for emergency cardiac
procedures. The rooms are very close to the intensive care and sub-
intensive cardiology care areas, in order to allow the shortest
possible response time for the invasive treatment of at-risk patients.
A dedicated lift also guarantees rapid transport to one of the two
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cardio operating theatres on the first floor, in an emergency.
Operations (for which a team is available 24 hours a day, 365 days a
year, guaranteeing continuous support for emergencies) are carried
out in collaboration with expert technical and nursing staff. Patients
having to undergo diagnostic tests or invasive treatment in the
Invasive Cardiology Section are admitted to the Cardiology Division
on the day before, or even the same day as the procedure. There is
guaranteed priority access to the Cardiology Intensive Care Unit, if
this should be necessary.
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ELECTROPHYSIOLOGY AND ELECTROSTIMULATION SECTION
Location: 3rd floor, Cardiology Complex, Cattinara Hospital
Director: Dr. M. Zecchin
Each year, more than 450 pace makers are fitted or replaced,
together with 120 defibrillators and cardiac resynchronization
devices. The trend in electrophysiology procedures and operations,
and the placement of defibrillators and resynchronization devices is
rising all the time.
Pace makers, defibrillators and resynchronization devices are placed
under the skin (usually in the left subclavian area), during a minor
operation under local anaesthetic. They are linked to the chambers
of the heart by one or more permanent electrode catheters.
The duration of surgery can vary depending on the device and
anatomical variations.
At present, the Laboratory also deals with electrical cardioversions
and plastic surgery on the pouches of pacemakers and defibrillators.
Operations are also carried out to remove the devices, ranging from
the replacement of used batteries to the more complex removal of
chronically implanted electrode catheters.
Patients from other divisions are formally re-transferred and treated,
according to protocol, in their original division. If necessary, at the
surgeon’s discretion, the patient can be treated in the Cardiology
Division.
Extraction of electrodes: after the procedure the patient is usually
transferred to the Coronary Unit for at least 8-12 hours. There is
guaranteed priority access to the Cardiology Intensive Care Unit, if
this should be necessary.
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CARDIOLOGY WARD
Location: 2nd floor, Cardiology Complex, Cattinara Hospital
Director: Dr. G. Lardieri
30 beds and 2 day hospital beds.
Each room has 2 beds and a full bathroom with shower. There is a
TV socket for patients’ own equipment.
Patients who are not confined to bed can use the lounge where they
can eat their meals, watch TV, read books and magazines from the
library, or meet their relatives and other visitors. There are coffee
machines, drink and snack machines, and a card-operated public
telephone.
On request, there is a paid barber/hairdressing service (ask a
member of staff).
About 3,000 patients are admitted to the ward every year. 60% are
resident in Trieste and the surrounding province, 30% are from the
Isontino-Giuliana region and further afield, while 10% are admitted
under the day-hospital system (residents and non-residents). 35% of
those admissions are planned, mainly for scheduled Invasive
Cardiology treatments (hemodynamics or electrophysiology), 43%
are urgent admissions from the Emergency Ward or patients referred
from cardiology outpatient facilities, other hospital departments and
other institutions, in an unstable condition or who cannot be
discharged. The remaining 23% are patients transferred from the
Coronary Unit for the post-acute phase, active mobilisation and
rehabilitation prior to discharge.
80% of the beds are fitted with advanced telemetry monitoring
systems which evaluate the arrhythmic profile and changes in the
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EGC (the onset of arrhythmia, ischemic changes on the ECG trace)
over a 24-hour period. 9 beds also have continuous monitoring of
saturimetry (constant measurement of the percentage of oxygen in
the blood).
The average stay is 5 days.
Patients are usually discharged to their homes, but ongoing care at
home can also be arranged, and in special conditions or for specific
illnesses, staff will discuss with the patient and his family the option
of transferring to nursing homes, Cura Pineta del Carso care home,
or the patient’s local hospital.
For patients admitted after a myocardial infarction, there is an inter-
hospital cardiology motor rehabilitation programme, run by
physiotherapists with specific cardiovascular training.
On discharge, medical and nursing staff will explain the discharge
letter to the patient. This letter contains the results of all the tests
carried out (and a CD of angiographic procedures, and a pacemaker
file for electrophysiology implants), a treatment plan (where drugs
are required) and the date of the next clinical appointment. The first
cycle of treatment is carried out with drugs provided by the hospital
pharmacy.
A consolidated Organizational Model ensures that on discharge from
hospital, the patient will receive care from his own general
practitioner and cardiologist, and from the local health authority’s
Continuity of Care service, in particular from the Cardiovascular
Centre with whom joint protocols have been established and are
regularly updated as part of the work of the Inter-Hospital Cardiology
Department of the Giuliano-Isontina Region.
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Alarms and signals
In the ward rooms there are pieces of equipment such as cardiac
monitors, infusion pumps etc. which emit audio/visual signals. The
functioning of this equipment is controlled by staff.
These alarms can sometimes be very sensitive, and can be activated
even when there is no risk. This is why relatives should not be
alarmed, as the staff will check the situation and take the appropriate
action.
Due to possible interference with electromedical equipment, mobile
phones must not be used, except where strictly necessary and for
short conversations. We would ask you in any case to switch off the
ring tone of any mobile devices.
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CARDIAC ULTRASOUND
Location: Ground Floor, Cardiology Complex Cattinara Hospital –
open from Monday to Saturday from 8.30 a.m. to 3 p.m.
Director: Dr. B. Pinamonti
Echocardiographs are carried out in order to identify and investigate
clinical cardiovascular problems. Each year, around 10,000 full
cardiac ultrasound tests are carried out (M-mode, bidimensional,
tridimensional, Doppler, color Doppler, transesophageal,
pharmacological and ergometric echo stress tests and echo
contrasts).
A cardiac ultrasound test generally consists of a monodimensional
and bidimensional investigation, followed by an echo Doppler test
(pulsed, continuous wave and colour flow), required for a quali-
quantitative assessment of the structures of the heart, the major
veins and intracardiac blood flow.
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If specifically required, a transesophageal echocardiogram can be
carried out, in order to obtain a better view of the chambers and
valves of the heart, the presence of an endocavital thrombus, aortic
disease or endocarditic vegetation, or an echo stress test (usually
with dobutamine) to detect ischemic or vital myocardium. The
laboratory can also carry out three-dimensional echocardiograms.
A digitalized picture archiving system (PACS) connects the
echocardiographs, digital images and remote viewing feature.
These tests can be booked through the CUP appointment booking
service, according to a prioritisation system approved by the local
health authority and periodically reviewed.
ELECTROCARDIOGRAPHY
Location: Ground Floor, Cardiology Complex, Cattinara Hospital
The Electrocardiography Lab completes more than 20,000
registrations each year. The Cardiology Division carries out and
interprets electrocardiograms for:
Patients admitted to the Cardiology Division or monitored as
outpatients;
Patients admitted to other divisions of the hospital;
External patients referred from general practitioners (with the
GP’s referral note and an appointment booked through the CUP
booking service), or from the Emergency Ward.
A computerised system allows records to be transmitted, archived
and traced remotely, as well as the serial comparison of records and
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a connection to the district clinics, local health authority
Cardiovascular Centre, and the IRCCS at Burlo Garofolo Hospital.
These tests can be booked through the CUP appointment booking
service, according to a prioritisation system approved by the local
health authority and periodically reviewed.
HIGH-RESOLUTION AND HOLTER ELECTROCARDIOGRAPHY
Location: Ground Floor, Cardiology Complex, Cattinara Hospital
The High-resolution and Holter Clinic completes more than 2,700
recordings each year, using devices that enable monitoring over a
period of 24 hours to 3 months, with 3 or 12 channels.
Advanced software is available for heart rate variability testing, i.e.
variability, QT dispersion and ST variations (12 channels).
Holter testing, which is prolonged ECG monitoring, can pick up and
quantify paroxysmal arrhythmia that cannot be seen on a simple
ECG. It can also confirm or rule out whether or not the patient’s
symptoms are related to arrhythmia, measure the heart rate over a
24-hour period, and detect possible episodes of myocardial
ischemia.
High-resolution electrocardiography is a technique that can show on
the ECG readout whether there are any potential ventricular
irregularities. It is particularly important in patients with a history of
myocardial infarction or myocardial disease, who are at risk of
sudden death.
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This extremely specialised test is requested by doctors from the
Cardiology Division for patients admitted to the division, outpatients,
and those referred from other divisions in the hospital.
The Holter clinic also uses the Holter ABPM, an inflatable armband
device which records arterial pressure day and night, in order to
optimise anti-hypertension treatment for patients who have difficulty
in controlling arterial pressure.
Holter tests for signs of arrhythmia can also be booked through the
CUP appointment booking service, according to a prioritisation
system approved by the local health authority and periodically
reviewed.
ERGOMETRY AND TILT TESTS
Location: Ground Floor, Cardiology Complex, Cattinara Hospital
The Ergometry and Ergospirometry Lab, which evaluates oxygen
consumption, carries out approximately 1,500 tests each year.
A stress test is carried out before and after a cycle of cardiac
rehabilitation, and for diagnostic purposes in patients with known or
suspected cardiac disease, to look for signs of inducible ischemia or
stress-induced cardiac arrhythmia.
The test is always preceded by a specialised cardiology consultation.
The tilting test is recommended in a few selected cases of recurrent
fainting in which the clinical assessment, prolonged ECG monitoring
and neurological tests have proved negative.
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The test is requested by the doctors of the Cardiology, Emergency
Medicine and Clinical Neurology Divisions. The information given by
general practitioners and other hospital divisions is always given to
the director of the Arrhythmia or Pacemaker Clinics.
DIVISIONAL OUTPATIENTS’ SERVICE
Location: Ground Floor, Cardiology Complex, Cattinara Hospital,
open Monday to Friday from 8.30 a.m. until 3 p.m.
The Cardiology Outpatients’ Service is for "internal" patients admitted
to other divisions (pre-operative, peri-postoperative care, and
patients from internal departments) and “external” patients requiring
specialist care and cardiology testing prior to admission or after
discharge from our division or another department of the hospital.
The consulting service for internal patients is governed by a specific
procedure and document approved by the Healthcare Directorate,
and is approved by a multidisciplinary team from the university and
hospital, which determines the types, targets, procedures and timing
of the consultations. The consultation reports and all diagnostic tests
are available on the Cardionet-G2 system.
PACEMAKER AND DEFIBRILLATOR CLINIC
Location: Ground Floor, Cardiology Complex, Cattinara Hospital,
open from Monday to Friday, from 8.30 a.m. until 1.30 p.m. (Tel:
preferably between 12 and 1 p.m.) Monday and Friday from 8.30 to 9
a.m.: removal of stitches;
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Monday, Wednesday, Thursday, Friday between 9 a.m. and 1
p.m.: checking of pace makers;
Tuesday, between 9 a.m. and 1 p.m.: checking of defibrillators
and resynchronization devices;
The pace maker unit is intended for patients who have been fitted
with a pace maker or automatic defibrillator at the Cardiology
Division or other divisions, inside or outside the region. The nurses
and doctors working at the unit are specialised in arrhythmology and
electrophysiology and have an in-depth knowledge of the devices
and programmers.
The subsequent appointment is scheduled at each visit. The date
and time of the appointment is noted in a specific diary, and clearly
marked on the record sheet which is always handed to the patient at
the end of the visit.
If an unscheduled visit is necessary, the patient can access the
department at the written request of his own doctor (addressed to the
Pace maker Department of the Cardiology Division, Cattinara
Hospital), directly by telephone. Each year, around 3,500 pace
maker checks are carried out, as well as 300 tests on defibrillators
and resynchronization devices.
The staff can be contacted during the above hours.
CLINICS FOR CARDIOMYOPATHY AND HEART FAILURE,
COMPLEX ANGIOPLASTIES AND PERCUTANEOUS AORTIC
PROSTHESES, PERCUTANEOUS TREATMENT OF
CONGENITAL DEFECTS
Location: Ground Floor, Cardiology Complex, Cattinara Hospital -
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Open from Monday to Friday (8.30 a.m. until 3 p.m.); the division is
operational throughout the day, by appointment. An answering
machine is always in operation.
The Cardiomyopathy and Heart Failure Clinic is intended for heart
patients suffering from cardiomyopathies, heart failure and/or
ventricular dysfunction. Its aim is to plan an accurate, rigorous
diagnostic procedure, provide information for genetic screening,
optimise pharmacological treatment and provide indications for
invasive procedures or surgery, including heart transplants. The unit
has been organised to carry out personalised clinical tests on the
patients’ needs, and to provide rapid responses without waiting
times, in the case of clinical destabilization or complications.
Clinical and/or instrumental tests are carried out on patients
discharged from the Cardiology Division or other divisions in the
hospital, who require tests at a dedicated unit, or on selected
external patients (usually after contact from the referring cardiologist,
or by the sending of documentation), admitted to accredited hospitals
inside or outside the region, or patients referred by personnel from
the Emergency Ward.
Our links with the IRCCS at Burlo Garofolo Hospital, the International
Centre for Genetic Engineering and Biotechnology and the University
of Denver in Colorado help to support our work related to clinical and
molecular genetic aspects of cardiomyopathies.
Due to the highly specialised nature of this service, admission to the
Heart Failure Clinic is selective, and will be discussed beforehand by
the referring physician and the hospital staff, or at least assessed on
the basis of a written report sent by the patient’s doctor.
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DIAGNOSTIC AND INVASIVE ELECTROPHYSIOLOGY AND
ARRHYTHMIA CLINIC
Location: Ground Floor, Cardiology Complex, Cattinara Hospital.
Open from Monday to Friday (8.30 a.m. - 12.30 p.m.). The unit is
operational throughout the day, by appointment.
The Electrophysiology and Electrostimulation Clinic is dedicated
to the assessment and invasive treatment of arrhythmia, whether
hypokinetic (bradyarrhythmia), or hyperkinetic (tachyarrhythmia).
An electrophysiological assessment or study will highlight any
anomalies in the electrical impulse conduction system, and over-
excitability of the myocardium tissue, by means of central venous
electrode catheter insertion. In many cases, the procedure is
followed by the treatment itself, using the same electrode catheters
which are able to neutralise the small area of tissue responsible for
the arrhythmia by delivering high-frequency electromagnetic waves
(RF ablation).
The Arrhythmia Clinic is dedicated to patients with particularly
complex arrhythmic problems or those who are potentially sensitive
to non-pharmacological treatment (particular trans-catheter ablation
and the fitting of advanced resynchronization and defibrillation
devices).
Clinical and/or instrumental tests are carried out on patients
discharged from the Cardiology Division or other divisions in the
hospital, who require a specialised arrhythmia test, on selected
external patients admitted to private hospitals in the Trieste area, or
elsewhere in the region, external patients referred by external
cardiologists, internists and general practitioners in Trieste and the
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surrounding area, and patients referred by personnel from the
Emergency Ward.
Due to the specific characteristics of the Arrhythmia Clinic, admission
is selective, and should be discussed between the referring
physician and departmental supervisors beforehand, or at least
assessed on the basis of a written report sent by the patient’s doctor.
The department treats about 50 patients every month.
The time of each appointment is determined every three months, by
the doctors responsible for this type of treatment.
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CARDIOLOGY UNIT AT OSPEDALE MAGGIORE; CARDIAC
REHABILITATION
Location: Ospedale Maggiore, via Pietà 2/2 (Distretto), 1st floor
34134, Trieste
Director: Dr. P. Maras
Tel: 040 – 399 2906; fax: 040 – 399 2208
Email: [email protected]
This Unit provides urgent and/or scheduled consultation services for
patients admitted to the following divisions: the Emergency Ward,
Critical Care Unit, 2nd Medical Division, Motor Rehabilitation, Nephrology
and Dialysis, Infectious Diseases, Oncology and Radiotherapy.
It also provides pre-operative consulting services for Stomatology,
Orthopedics, Ophthalmology and Day Surgery.
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It carries out diagnostic ergometry procedures on patients referred from
hospital cardiology units or cardiologists within the Trieste No. 1 local
health authority, after approval by the cardiology specialist.
15 patients are given an ECG each day after booking an appointment
through the booking desk (CUP), while “code red” urgent ECG requests
are dealt with immediately.
1 Holter test each day is carried out through the CUP, while another 2
daily tests are allocated to the wards of Ospedale Maggiore and
patients being treated in Rehabilitation.
Cardiac ultrasound procedures are provided twice a week, in
collaboration with the Echocardiography Lab at the Cardiology Complex,
for patients admitted to Ospedale Maggiore and Rehabilitation.
The division also organises and carries out, in collaboration with Nuclear
Medicine, a weekly session of myocardial stress scintigraphy (about 6 -
7 patients per day are sent from the Cattinara Cardiology Division, local
and regional cardiologists from Monfalcone and Palmanova.
This Unit also provides Cardiac Rehabilitation, which is defined as “all
the procedures needed to ensure the best possible physical,
psychological and social wellbeing for heart patients, so they can
maintain or regain their place in society”.
Rehabilitation at the Cardiology and Cardiac Surgery Division starts
early, and is led by physiotherapists during the patient’s stay in hospital.
After that, at least all patients with STEMI and NSTEMI myocardial
infarction, patients who have undergone aortocoronary bypass
operations, those with valve disease who have also had a bypass, and
patients discharged from Cardiology after coronary angioplasty are
treated for a further 3 months.
The procedure consists of a clinical examination, followed by a
submaximal stress test for STEMI cases and patients who have
undergone surgical revascularization (after one month for acute
33
myocardial infarctions and as soon as possible for the second
category), in order to start the rehabilitation process.
A four-week exercise programme (exercise bikes) is planned for each
patient, with 2-3 visits a week.
At the end of the first 4 weeks, the patient then undergoes a clinical ECG
assessment. A further series of gym-based group activities is planned,
for another 4 weeks (2 or 3 visits a week).
After 3 months, the patient’s treatment ends with a clinical assessment,
ECG, Holter test if necessary, and a stress test. He is then referred to
his own doctor for check-ups with the local cardiologist.
For selected patients with unresolved ischemia issues, or uncontrolled
heart failure, the clinical follow-up will continue for up to 6 months.
The outpatient service is aimed at patients discharged from hospital with
a diagnosis of acute myocardial infarction, from the medical units of our
own institution, and other hospitals.
The work of the Cardiology and Cardiac Rehabilitation Unit is governed
by internal and interdepartmental protocols and procedures.
COMPUTERIZATION
The Division has implemented advanced computer systems for the
archiving, transmission and recording of bio-images acquired in
digital format from various diagnostic imaging sources. The network
(PACS) creates subsystems for the acquisition, display and
printing out of images, for image management and ar chiving ,
and finally for networked communications. The network connects
the various parts of the system, integrating the PACS with public
healthcare computer systems, and distributes data so that it can be
accessed by staff (access is always password-protected), so that the
34
patient’s history can be accessed even if the records are held by
healthcare facilities some distance away.
35
ADMISSION TO THE CARDIOLOGY DIVISION
Patients are admitted to the division as follows:
ORDINARY scheduled admissions apply to patients already
registered with our division, with a planned date of admission for
invasive tests or diagnosis;
URGENT admissions, via access to the Emergency Ward or
urgent cases from other regional hospitals (other divisions,
cardiovascular centres in the surrounding area) or other regions.
DAY-HOSPITAL admissions are used for interventions or
procedures which do not require a stay in hospital (e.g.
electrophysiological studies, right-side catheterization,
replacements of pacemaker or defibrillator batteries, electrical
cardioversion etc).
Preferential access to the EMERGENCY WARD is always
guaranteed.
TREATMENTS AND AVERAGE WAITING TIMES (as of 07/2010)
Treatment Average waiting time (days)
“Priority” cardiac ultrasound
Elective cardiac ultrasound
15
47
Cardiac ultrasound with contrast *
Transesophageal cardiac ultrasound *
Cardiac ultrasound with
physical/pharmacological stress *
Dynamic Holter ECG 2
High-resolution electrocardiogram *
36
Electrocardiogram 2
24-hour blood pressure monitoring *
Ergometric cycle test *
Mobile platform stress test *
Tilt test *
* Access after specialised cardiology examination w ith internal appointment, as necessary.
PAIN CONTROL
A patient’s pain levels are constantly monitored by physicians and
nurses, during a stay in hospital, so that treatment is compassionate
and tailored to the needs of the individual. We use a mixed scale
which can be easily understood by the patient. It ranges from 0 (no
pain) to 10 (intolerable pain).
INFORMED CONSENT
Patients have the right to receive full information about the progress
of their diagnosis and treatment, and to give or withhold their consent
to proposed treatments and procedures.
Pain? No thanks!
37
During the patient’s stay in hospital, general consent will be
requested, as well as specific consent, as required by law, for
invasive and/or more complex procedures.
The following procedures require informed consent:
Healthcare, diagnostic, therapeutic and surgical treatments;
Clinical trials
The use of personal information.
The consent procedure involves various phases and incorporates
informative material that is periodically updated and available at any
time.
PATIENTS’ INVOLVEMENT IN THEIR TREATMENT
A strong alliance between physician and patient and the creation of a
trust-based relationship are essential for effective healthcare. We
pay great attention to combining a professional attitude, technical
skill and technological advances in diagnosis and treatment with a
willingness to listen, compassion, and regular information for patients
and relatives.
The patient is entitled to participate in the preparation of his
treatment plan, and to be informed on how his illness could impact
his quality of life, the treatments and procedures which could
eliminate or at least reduce potential pain and suffering.
All patients can interrupt the clinical care process at any stage, or
refuse a certain type of treatment. Medical staff must inform the
patient about the possible consequences of such a decision.
Information about the patients’ state of health is given by the
consultant and doctors.
38
For obvious reasons of confidentiality, all clinical information is only
relayed to members of the patient’s close family, or other people
expressly designated by the patient.
Relatives can see the medical records together with the doctor.
To guarantee continuity of information, it is a good idea that the
same person regularly speaks to the doctor. Family members are
regularly involved in the patient's care programme.
At the time of discharge (and in special cases, during the patient’s
stay in hospital), the patient’s general practitioner and specialist will
be informed, in a detailed letter of discharge, about the reasons for
the patient’s stay in hospital, his clinical condition, outlook,
educational aspects, and care programme.
N.B.: FOR REASONS OF PRIVACY, INFORMATION ABOUT PATIENTS’ CONDITIONS WILL NOT BE GIVEN OVER THE TELEPHONE. YOU ARE KINDLY ASKED NOT TO INSIST.
NO!
39
HOW TO IDENTIFY HOSPITAL STAFF BY THE COLOUR OF THEIR UNIFORMS
white
physicians, biologists, chemists, physicists, pharmacists
green with dark
green collar
nursing coordinators
green
registered nurses
yellow
general nurses
blue with white collar
public health and welfare workers
blue
auxiliary staff
pale blue with white
collar
senior technicians
pale blue with dark
blue collar
physiotherapists, speech therapists, orthoptists and occupational therapists
pale blue
technicians (radiology department, laboratory etc.)
white with orange
strip on pocket
On the ward, you may also see volunteers. You can recognise them
40
by their white shirts, bearing a tag with their name and the
association to which they belong.
RELIGION
The faith of any patient admitted to our hospital will be respected.
Ministers of your own religion are welcome to attend.
A Catholic priest visits the Cardiology Division daily.
INFORMATION FOR PATIENTS
Patients will receive information from doctors and nurses either
orally, on information sheets, informed consent forms, or by means
of explanations about the intended programme of treatment and
tests.
For foreign patients, a cultural mediator will be asked to intervene to
assist in explaining the tests, treatment programme and to liaise with
the doctor about the care programme.
41
CULTURAL MEDIATION
A cultural mediator is someone who
speaks the native language of a non-
Italian patient, helping him or her to
understand what is being asked,
prescribed or proposed by the
physician and other hospital staff.
A cultural mediator intervenes so that non-Italian patients can
understand:
the health issue;
urgent requirements;
how and why the clinical tests and diagnostic procedures are
carried out, and the types of consent required;
the diagnosis
treatment to be followed after discharge from hospital.
VISITORS
It is certainly beneficial for patients to receive visitors, but more than
two per room can create noise and discomfort, given the limited
space available and the presence of other patients.
Cardiology patients who are able to get up can be visited by friends
and family in the lounge.
Young children should not be brought to the hospital, in order to
protect their health. If it cannot be avoided, they should if possible
42
stay in the lounge area.
In particularly serious cases or for specific reasons, family members
will be allowed to remain with their relative at other times, with
limitations dictated by specific situations that may arise.
Please always provide nursing staff with your telephone number.
If a patient is transferred or there is a sudden change in condition,
his family will be informed by telephone, at any time, by the nursing
staff or doctor on duty.
For relatives: if you are handed your relative’s personal effects for
safekeeping, please check carefully that everything is in order before
signing for receipt.
For patients: if you have to leave the ward you must always inform
the nursing staff of where you are going, and for how long.
PATIENT SAFETY
The Cardiology Division has implemented measures to protect
patients’ safety, including the correct identification of each patient by
means of an ID bracelet. Other measures have been put in place to
improve the management of high-risk drugs (concentrated
electrolytes are not found on the wards except where clinically
necessary and authorised by hospital policy, and where measures
have been implemented to prevent accidental administration).
Measures are in place to:
• reduce the risk of hospital infections;
• reduce the risk of injuries to patients caused by falling;
• prevent medical errors and analyse warning events;
• identify patients accurately;
• communicate effectively with patients and their relatives;
43
• reduce delays in the various care processes.
The environment is constantly monitored, and electromedical
devices undergo periodic controls and safety and maintenance
checks.
MOBILE PHONES
The use of mobile phones is PROHIBITED
as it can interfere with the equipment on the
ward.
MEALS
Meals can be chosen each day, based on the diet prescribed by the
doctor.
Breakfast: 7.30 a.m. Lunch: 12 noon Dinner: 6:30 p.m.
If the patient wishes to bring food from home, the doctor or nurse
must be informed beforehand. Some illnesses do not permit an
unrestricted diet. Bringing food in from home without our knowledge
could harm your relative.
44
A heart patient’s diet must take into account the risk factors involved
in cardiac diseases. In general, we recommend:
maintaining a desirable weight (avoid becoming overweight)
doing physical exercise (an agreed amount of aerobic exercise,
every day)
reducing the amount of food that contains saturated fats, total
fats and cholesterol (butter, red meat, fatty fish etc.). The main
condiment should be extra-virgin olive oil, used cold and poured
on to the food after cooking
controlling the amount of simple sugars (cakes, ice-cream and
chocolate but also excessive amounts of fruit and dairy
products), salt, alcohol, and caffeine
varying the diet as much as possible, by eating fruit and
vegetables in season.
Every action the body performs – including digestion - means work
for the heart. Correct nutrition can reduce the strain on the heart,
which is why we recommend:
THE PROPER DIET FOR
CARDIOVASCULAR DISEASES
Dietary advice from the Cardiology Division
and Dietetics Service.
45
spreading food intake throughout the day (5 meals for example)
and avoiding large meals
chewing thoroughly and slowly to aid digestion
choosing simple foods over elaborate dishes
avoiding fried food and dressings
herbs (rosemary, sage, basil, oregano, parsley, garlic), lemon,
vinegar and plain tomato sauce can be used to flavour food
drinking plenty of liquids such as plain water, chamomile tea,
barley drinks, natural infusions or weak tea.
choosing plant-based foods (bread, pasta, fruit, vegetables, oils
and legumes, which are cholesterol-free and very low in
saturated fats). Meat should be limited to no more than 3-4 times
out of 14 meals per week, and preference should be given to
poultry, rabbit, turkey, and lean cuts of beef and horsemeat.
Fish should be eaten 6-8 times out of 14 meals per week. Fish -
such as sole, trout, turbot, skate, monkfish, cod and oily fish - is
one of the best choices of animal-derived foods, due to the
content of essential fatty acids. Seafood, eels and salmon are
not recommended.
Limit your intake of cheese to no more than 1-2 times a week,
giving preference to fresh cheeses such as ricotta made from
cow’s milk, or mozzarella. There is no such thing as “low fat”
cheese, only cheese that contains less fat than others. Milk or
yogurt, preferably low-fat, should be consumed once a day for
its calcium content.
Legumes (beans, peas, soya, chick peas and lentils etc.) are
also a source of protein, and contain no saturated fats or
cholesterol, and make a good choice for the second course of a
46
main meal.
Charcuterie products and sliced meats are not recommended,
due to their content of salt, saturated fats and cholesterol. Parma
ham, lean cooked ham with the fat removed, and bresaola is
permitted occasionally.
Eggs should be limited, and offal (brains, liver, kidneys) must be
avoided because they are particularly high in cholesterol.
If you are not overweight, bread, pasta and rice (including
wholegrain rice) can be consumed quite freely, paying careful
attention to the dressing or sauce used, and always keeping to
the desired weight.
Vegetables (fresh or frozen) contain an important source of
fibre, and are known for their “fill-you-up” effect. They should
therefore be consumed regularly, at least twice a day.
Fruit can be consumed as a mid-morning and mid-afternoon
snack. The recommended amount is 2-3 pieces of seasonal fruit
per day, but nuts and oily fruit should be avoided.
On discharge, the patient will be given personalised dietary advice
based on his illness and other risk factors (such as a low-sodium diet
in the case of hypertension; in the case of heart failure care must be
taken with liquids, or in the case of high cholesterol, attention must
be paid to the amount of cholesterol-rich or fatty foods, etc.).
47
DRUGS
Please note that all drugs, even those considered "harmless",
contain chemicals that interact with each other. These substances
can increase, reduce or even cancel out the effect of drugs
prescribed by a doctor. We therefore recommend that patients do not
take or keep personal drugs. If a specific treatment has to be
continued, the doctor should be informed to have the treatment
validated and ordered from the Hospital Pharmacy.
CASH AND VALUABLES
Although the department is constantly
monitored, it is not advisable to leave
large sums of cash or valuables with
the patient.
RULES OF CONDUCT
If you are admitted to the Cardiology Ward, for your own safety you
must not leave the ward without the express authorisation of a
member of staff.
If you decide to leave the hospital against the will of the staff looking
after you, you will be asked to sign a disclaimer.
If you have any queries, the staff are at your disposal.
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CERTIFICATE OF ADMISSION
A certificate of admission to hospital, required in order to justify an
absence from work, study or for insurance purposes, can be
obtained from the Admissions Administration Office on the 3rd floor,
close to the Emergency Ward, from Monday to Friday from 7.15 a.m.
until 6.45 p.m. and on Saturday from 7.15 a.m. until 6 p.m. (closed
on Sundays).
COMPLAINTS
Complaints should be made to the Public Relations O ffice (open
from Monday to Friday, 8 a.m. – 3 p.m.) as follows:
in person
by telephone (Tel. 040/3994035 040/3992237)
by letter, fax (040.399 2486) or e-mail
using the special form available at the Information Points and
complaint boxes located in both hospital sites.
DISCHARGE FROM HOSPITAL
The patient will be handed a detailed letter of discharge, stating the
diagnosis and details of the diagnostic tests carried out during his
stay, the latest blood tests, a copy of the electrocardiograph readout,
any other procedures he has undergone, drugs to be taken at home,
guidelines on behaviour, diet and recovery, and post-discharge
check-ups, appointments with our divisional outpatients’ service on
the Ground Floor, or at the Cardiac Rehabilitation Unit of Ospedale
Maggiore, or the Cardiovascular Centre in Via Farneto (ASS1).
49
Patients fitted with pace makers will be handed a folder containing
information about the type of pace maker and subsequent
examinations.
Patients who have undergone a coronarography and angioplasty will
be handed a CD with a copy of the test, to be kept and brought with
the patient at the time of any subsequent admission to hospital.
The patient will receive a letter, addressed to his own doctor,
containing the diagnosis, recommended treatment and details of the
main tests carried out.
You are asked to hand the discharge report to your own doctor and
cardiologist as soon as possible.
In order to improve the quality of our service, we would be grateful if
you would report any inconvenience or problem to the medical staff
or nursing coordinators.
If the patient requires continued treatment before returning home, a
Continuity of Care programme will be set up (the home nursing
service in the patient’s district will be contacted in order to set up a
support network to help the patient and his family to recover as
efficiently as possible).
50
HOW TO REQUEST A COPY OF YOUR MEDICAL RECORDS
Copies of medical records can be requested by the patient himself or
by another person on submission of the patient’s ID card and that of
the person requesting the records. When requesting the records of a
minor, a self-certification must be attached, confirming the
applicant’s status as parent or legal guardian. If requesting the
records of a deceased person, the request must be accompanied by
a self-certification confirming that the person making the application
is the legitimate heir of the deceased.
The request can be submitted:
After discharge from hospital, IN THE EVENT OF
ACUTE SYMPTOMS (prolonged chest pain, sudden
shortness of breath, prolonged palpitations) YOUR
FIRST POINT OF CALL IS THE EMERGENCY WARD
where the consultant cardiologist will be called.
51
at the CUP appointment booking service, at Cattinara Hospital or
at Ospedale Maggiore
Where to collect the records – Medical records can be collected
from the CUP desk, or can be sent to your home (postal charges to
be borne by the person making the request)
How to collect them – The records can be collected by the patient
himself or by a person with a signed authorisation form, in which
case the person collecting must have a photocopy of the patient’s ID
card.
When requesting copies of medical records from the CUP desk, the
patient must pay a fixed charge (in advance). When the records are
collected, he will have to pay a fee which varies depending on the
number of pages to be photocopied.
CONTINUITY OF CARE
Continuity of care between the Trieste University Hospital and the
Trieste Local Health Authority No. 1 is intended to provide assistance
to the patient after discharge from hospital, so that he can receive
care from the district health service and his general practitioner,
other public health workers and voluntary associations.
The hospital wards will liaise with the district home nursing service,
in order to:
increase the number of patients benefiting from post-hospital
care, especially the elderly, those suffering from heart disease,
bronchial disease, phlebopathic patients or diabetics with a history of
repeated admission to hospital;
52
guarantee prompt, efficient care.
During the patient’s stay in hospital, the best treatment procedure
and post-discharge treatment programme will be agreed with the
patient and his relatives. In some cases patients are referred to the
Cardiovascular Centre, their own cardiologist, or in certain more
complex cases to the Pineta del Carso care home or other nursing
homes, to continue their rehabilitation in a protected environment.
ORGANISATION, COMMUNICATION, TRAINING AND QUALITY
CONTROL
Life at the Cardiology Division is characterised by scheduled
meetings, and other opportunities for the discussion, analysis,
organisation and updating of clinical activities.
Every morning at 8.30 a.m., from Monday to Saturday,
clinical reports, critical assessments, discussion and
planning of operational issues;
At 2.30 p.m. every day, Monday to Friday; discussion of
cases involving invasive cardiology procedures;
From 8 – 8.30 a.m. every Wednesday morning; clinical
update;
At 3 p.m. every Wednesday afternoon, discussion of
cardiac surgery cases, open to fellow cardiologists from
the Giuliano Isontina region;
Every Friday at 8 a.m.: cardiac ultrasound meeting;
One Friday a month: discussion of individual cases:
Cardiomyopathy and Heart Failure Clinic, or Molecular
Cardiology meeting.
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54
SCIENTIFIC AND RESEARCH ACTIVITIES
Knowledge transfer and clinical research have always played an
important role in the life of the Cardiology Division. These activities
mainly revolve around medical and epidemiological aspects, the
causes of disease, and the natural history of patients with myocardial
disease or heart failure.
Since the 1980s, research in this field has been organised through
the “Cardiomyopathy and Heart Failure Study Group”, seen as a
national centre of excellence, which gathers its data from a
structured Register.
Structured research activities mainly relate to the following areas:
Myocardial Disease and heart failure;
Genetically-determined dilated cardiomyopathy;
The treatment of heart failure;
Pulmonary arterial hypertension;
Anatomoclinical epidemiological correlation studies;
Histomorphological and immunohistochemical studies of
endomyocardial biopsy;
Molecular Cardiology, Cellular Therapy and
Neoangiogenesis.
Over the years, there have been many international randomized,
multicentre, controlled clinical trials and Register activities in the
following areas: ischemic cardiopathy, invasive cardiology, acute and
55
chronic heart failure, arrhythmias, cardiovascular prevention and
rehabilitation.
The patient is always given consent forms for the use of personal
data, the inclusion of clinical data in observational registers, and
inclusion in clinical trials.
Medical staff play an educational and tutorial role for students of
medicine and surgery, and for various specialization schools.
There is regular collaboration (the result of years of intense research
activity), with the Colorado Clinical & Translational Sciences Institute
(University of Colorado, Denver, USA), the Genetic Medicine Unit at
the Burlo Garofolo Paediatric Hospital, Trieste, the International
Centre for Genetic Engineering and Biotechnology (ICGEB) in
Padriciano, Trieste, the Institute of Pathological Anatomy of Trieste
University and various other university institutions and international
hospitals.
NOTE
This booklet contains information valid at time of printing and is
periodically updated. Among the other issue, however, may
intervene in the operation changes.
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ACCREDITED FOR ORGANIZATION BY
JOINT COMMISSION INTERNATIONAL Written by the Communications Office in collaboration with the Public Relations Office, based on text and pictures supplied by the Cardiology Division (Dr. Francesca Brun) in line with Joint Commission International Accreditation standards. Tel. 040 – 399 6301; 040 – 399 6300; fax 040 399 6298 e-mail: [email protected] Strada di Fiume 447 – 34 149 Trieste
Revision 003 – 7 march 2012