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The syndrome of hemorrhagic shock and encephalopathy (HSE) was first described by Levin et al. in 1983 [1] but not until recently has it been considered to be a newly identified devastating disorder [2, 3]. The main features of this syndrome consist of sudden onset of shock, coma, convulsions, coagulopathy, renal and hepatic dysfunction. The mortality rate is very high with surviving patients suffering from severe neurologic sequelae [4]. In review of the literature [1], we did not find any reports of cerebral infarcts. Recently we managed two patients with this syndrome, both of whom had CT scand findings consistent with cerebral infarctions.

The typical strategies that generic counselors use to establish rapport with patients in face-to-face situations are undermined by the used of televideo. Leaning forward to show concern and support, establishing direct eye contact to convey interest, respect, and receptiveness, and being able to reach out and touch someone when they display signs of anxiousness or fear: these things just do not “work” in a televideo counseling session. In a series of pretest using PC computers networked to simulate an Internet-like connection, video cameras, and headsets, we have developed a set of strategies for establishing a physical and social context conducive to the development of rapport in televideo counseling sessions. The physical context of the session may be optimized by altering camera placement to approximate direct eye contact and to permit viewing of both facial features and hand gestures; and by orienting the patient to the unique features of the televideo equipment (such as cursor movements, the short audio time delay, positioning of visuals aids, and so on). The social context of the televideo consultation may be made more conducive to the development of rapport by establishing patient control over the situation (having them adjust the camera for better viewing, encouraging the patient to use non-verbal cues to interrupt the counselor, and having the counselors practice ways of repairing communication break-downs that occur from “talking over” one another). These general strategies may be supplemented by having the counselors practice the kinds of rapport-building techniques that seem to work in both traditional face-to-face and televideo counseling sessions: using non-verbal cues(smiling, nodding), verbally assessing patients understanding and perception of risks, verbally expressing empathy, etc. We are utilizing this protocol in an on-going prospective trial regarding the use of televideo genetic counseling in an advanced maternal age population.

The purpose of this pilot study was to evaluate the feasibility, technical performance, and effectiveness of prenatal genetic counseling in advanced maternal age (AMA) patients through the use of interactive video-conferencing (IVC). Eight volunteers were asked to complete a genetic history questionnaire prior to the IVC consultation. Participants received information regarding the risk of fetal aneuploidy and testing options to evaluate these risks. Counseling was provided by board certified genetic counselors. The counselor and the participants were located in separate rooms within the institution, having contact only through IVC. At each site, PC computers were networked to simulate an Internet-like connection. Additional hardware included Intel's ProShare Video System 500 with video cameras and headsets. Microsoft's NetMeeting was used for real-time video-conferencing and also for sharing custom-designed visual aid tools. Following each IVC consultation, participants were given questionnaires to assess: 1) the genetic and medical information gained during the consultation, and 2) the patient/couple's opinion regarding the efficacy of IVC generic counseling. A protocol was developed to optimize the physical context of the system, by altering camera placement to approximate direct eye contact, and verbally orienting the patient to the unique features of the IVC equipment. All participants indicated that they believed that the counselor was able to address their needs in the IVC session. Similarly, 7/8 patients “agreed” or “strongly agreed” that they were satisfied with the consultation via IVC; 8/8 participants felt that they were “well informed” about risks and options after the consultation; all agreed that the graphic visual aids used on the IVC monitor by the counselor aided in their understanding of their genetic risks. In regard to the equipment, 3/8 indicated that the IVC made them feel uncomfortable, while 5/8 participants agreed that “it did not take long” to feel comfortable with the system. Finally, when asked if they would prefer have genetic counseling at home through IVC over standard “face-to-face” counseling, 7/8 marked “agree” or “strongly agree". These results suggest that the use of IVC for genetic counseling is a feasible alternative to traditional face-to-face consultations. To further evaluate these findings, a prospective trial in AMA patients is underway in our institution.