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Challenges exist in respect of people with intellectual disabilities who, with the increasing life expectancy, have a growing risk of age-related degenerative conditions. Changes in bone health are associated with increasing age and the bone health of people who have intellectual disabilities is well documented in the literature as being poor in comparison to the general population. A heel scan clinic was set up in an intellectual disability service as a service improvement initiative. There were 12 females and 17 males scanned using a heel scanner. Only 3 (10.3%) people with intellectual disabilities were in the normal bone mineral density (BMD) range. Peripheral BMD screening for people has been shown to provide important information about the bone health of people with intellectual disabilities which has prompted further treatment by general practitioners and has the potential to provide an accessible way to obtain information on the bone health of people with intellectual disabilities.

Frailty is a common clinical syndrome that predisposes older adults to an increased risk of adverse health outcomes. With population aging, this will become an increasing challenge for the healthcare services; therefore, different models of healthcare training and provision are required to address these increasing demands. In Ireland, the National Clinical Programme for Older People (NCPOP) has partnered with The Irish Longitudinal Study on Ageing (TILDA) to deliver the National Frailty Education Programme. This demonstrates an innovative way in which evidence-based longitudinal research can be translated into clinical education and practice to improve patient care, following a Knowledge to Action (KTA) process. To the authors' knowledge, it is the first time that a longitudinal research study such as TILDA has employed such methods of translation and therefore, this collaboration could serve as an international model of translation and implementation for frailty and other areas of clinical priority.

Background : Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent intermediate state before frailty becomes established. Despite being widely-used in the literature and increasingly in clinical practice, it is poorly understood. Objective : To establish consensus on the construct and approaches to diagnose and manage pre-frailty. Methods : We conducted a modified (electronic, two-round) Delphi consensus study. The questionnaire included statements concerning the concept, aspects and causes, types, mechanism, assessment, consequences, prevention and management of pre-frailty. Qualitative and quantitative analysis methods were employed. An agreement level of 70% was applied. Results : Twenty-three experts with different backgrounds from 12 countries participated. In total 70 statements were circulated in Round 1. Of these, 52.8% were accepted. Following comments, 51 statements were re-circulated in Round 2 and 92.1% were accepted. It was agreed that physical and non-physical factors including psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life. Experts considered pre-frailty to be an age-associated multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It can be reversed or attenuated by targeted interventions. Brief, feasible, and validated tools and multidimensional assessment are recommended to identify pre-frailty. Conclusions : Consensus suggests that pre-frailty lies along the frailty continuum. It is a multidimensional risk-state associated with one or more of physical impairment, cognitive decline, nutritional deficiencies and socioeconomic disadvantages, predisposing to the development of frailty. More research is needed to agree an operational definition and optimal management strategies.

Background Frailty is associated with a prodromal stage called pre-frailty, a potentially reversible and highly prevalent condition before frailty becomes established. Despite this, there is no widely accepted definition of pre-frailty to support its early identification and management. This study applied an international consensus approach to define and better understand pre-frailty. Methods A modified electronic two-round Delphi Consensus study was conducted. In all, 23 experts from 12 countries with different backgrounds participated. The questionnaire was developed following a systematic literature review. An online consensus meeting was conducted with eight Delphi participants and two external experts. Qualitative and quantitative methods were employed for data analysis. An agreement level of 70% was applied for accepting statements. Results A total of 71 statements were circulated in Round 1. Of these, 52.8% were accepted. Fifty-one statements were re-circulated in Round 2, of which 92.1% were accepted. The online consensus meeting produced a consensus statement describing the concept, multi-factorial nature, and mechanism of pre-frailty as well as assessment, prevention and management approaches. All experts agreed that physical and non-physical factors such as psychological and social capacity are involved in the development of pre-frailty, potentially adversely affecting health and health-related quality of life outcomes. Practitioners should regard pre-frailty as a multi-factorial, multi-dimensional, and non-linear process that does not inevitably lead to frailty. It might be reversed or attenuated by targeted interventions. Brief, feasible and validated tools are recommended for opportunistic screening or case-finding followed by confirmation with multi-dimensional assessment. Conclusion It is difficult to establish consensus on one compact definition of pre-frailty, which is a multi-dimensional concept not only associated with physical impairment, but also with cognitive, nutritional, socioeconomic and other aspects of frailty. However, it may be too early to agree on an operational definition of pre-frailty since none yet exists for frailty.

Background: The National Integrated Care Programme for Older People (NICPOP), formerly NCPOP aims to support older people to live well in their homes by developing primary and secondary care services for older people, especially those with complex needs. The programme develops integrated intermediate care which traverses both hospital and community settings through multidisciplinary and interagency teams. This team-based approach to the integration of health services is a novel innovation in Irish health service delivery and will require, over time, a shift in cultures of care to allow for the development of competencies for inter-professional collaboration across the care continuum. The ECLECTIC project will develop an implementation framework for achieving, maintaining and monitoring competencies for interprofessional collaboration among multi-disciplinary teams charged with delivering care for older people across the continuum from acute to community settings. Design: The ECLECTIC research design has been developed in collaboration with the NICPOP. In phase one of the project, a co-design team will collaborate to define and shape competencies for interprofessional collaboration. Phase two will involve the delivery of a collective leadership intervention over a 10-month period with multidisciplinary professionals working with older people across two geographical regions (Mullingar/Midlands and Beaumont/Dublin North). Each group will comprise of members of two multidisciplinary teams charged with coordinating and delivering care to older people across the continuum of acute to community care. Observations of collaborative inter-professional working will take place before, during, and after intervention. In phase three of the study, analysis of the interview and observation data will be presented to the co-design team in order to develop an implementation framework for future teams. Discussion: The co-design process will develop core competencies and performance indicators for collaborative interprofessional working. The resulting implementation framework will be implemented nationally as part of the NICPOP.

peer-reviewed Aims and objectives: This study has aimed to examine key stakeholders’ perspectives, views and experiences regarding transfer documents, used when an older person is being transferred from a residential to an acute care setting. The objective of the study is to inform, in part, the development of an effective national transfer document. Background: For the effective and safe transfer of older persons from residential to acute care settings it is important to ensure that the transfer document encapsulates relevant, current and person-centred information to ensure a smooth, quality and safe transition. Evidence highlights that, where documentation has lacked vital and relevant information, the older persons experience negative impacts during the transfer process. Design: A qualitative descriptive study was conducted, following the COREQ checklist, to establish participants’ perspectives, views and experiences of using transfer documents. Methods: Focus group interviews (n=8) were conducted with a convenience sample of key stakeholders (n=68) in an Irish setting. The data were analysed using content analysis. Results: The findings have highlighted the important aspects for consideration in the development of future transfer documentation. The three broad categories, used to present the data findings are 1) existing transfer documentation, 2) design framework, and 3) essentials of care. Conclusions: The transfer document of the future is required to be concise, regularly reviewed, and with a user friendly colour coded design. Essential and current information, with an emphasis on person centeredness, must be in the first page, with more detailed supporting information in the subsequent sections. peer-reviewed

Introduction: Delirium (acute confusion) affects 1 in 8 acute hospital inpatients and is highly distressing for patients and families. It is associated with increased length of hospital stay, risk of falls, mortality and institutionalisation. Early detection improves outcome, whereas established delirium (present for a few days) is difficult to treat. Thus screening for delirium in at-risk patients is key to early detection and treatment to improve outcomes. Description of policy context and objective: NICE guidelines recommend daily delirium screening for high risk patient groups. However, delirium screening and assessment is poorly performed in Irish hospitals (Irish National Audit of Dementia, 2014). We aimed to develop a simple algorithm for delirium screening on hospital wards, helping staff to identify those patients requiring daily delirium screening and outlining the action to be taken when a patient screened positive for delirium. Targeted population: Hospital in-patients on any general medical or surgical ward (i.e. excluding Intensive Care Unit or orthopaedic/neurosurgery wards), with ward nurses performing the daily delirium screening and hospital doctors acting on the abnormal result. Highlights: (innovation, Impact and outcomes) The interdisciplinary national algorithm development team firstly developed an evidence-based algorithm. Two versions were developed- one using the 4AT test (a well-recognised short delirium screening test) and the other using a quicker, deconstructed form. Both versions were piloted in three hospital sites, in a single ward at each site, with extensive user evaluation of the algorithm. Further modification was performed, followed by a second pilot in a single hospital on four wards. The version using the regular 4AT was preferred by users. Staff required pre-use training particularly on how to score patient refusals and using the tool in a patient with severe dementia. A Frequently Asked Questions guide, and an online training tool were developed, to support staff use of the algorithm, based on the pilot studies. This algorithm is being rolled out nationally in 2017 so impact and outcomes can’t be assessed as yet. Comments on transferability: The delirium algorithm was developed for use in all acute hospitals in Ireland. It is highly transferrable to other countries. Conclusions: Any new policy or guideline requires extensive user engagement at all stages of development. Different hospitals have different resources and training needs. Extensive piloting of our proposed algorithm identified areas that required targeted training. This allowed resources to be developed to facilitate adoption of the national policy, targeted to specific end-users needs.

Rationale for this initiative: On admission and throughout the acute hospital stay, the main focus of the healthcare professional is the medical model of care, which revolves around the physical status of the patient (Dewar & Nolan 2013). Hospital staff work in a system where patient flow and lengths of stay are indicators of effective organisations (Shahin & Mahood 2007). The emphasis appears to centre on “What’s the matter with you” (Doyle et al. 2010). While the presenting health issue is a concern to the patient, their experience of hospital care is measured by the level of dignity, compassion and respect with which they are treated (HSE & Age Friendly Ireland 2015).The Service Plan explicitly emphasises that people’s experience of the health service must be “safe, of high quality, but also caring and compassionate” (HSE 2015 p. 3). Compassionate care involves knowing the patient as a person (Lown et al. 2011) and developing a relationship of equals where the carer conveys an understanding of the patient’s suffering in a way that alleviates some of that suffering (von Dietze & Orb 2000). There is a critical link between services who regard the patient as an equal contributor to their care, where their opinions are sought and valued, and the provision of compassionate care (NHS 2014).The “What Matters to You” (WMTY) initiative supports this concept. It is a process that seeks to identify the concerns of the individual admitted to hospital and, thereby, facilitates the delivery of person-centered, compassionate care.Description of the initiative: WMTY is an approach to care that promotes compassionate relationship-centred care (Dewar & Nolan 2013). It involves introducing a change in practice, whereby, nursing staff ask about what is important to the patient, rather than simply concentrating on their diagnosis and past medical history. The literature suggests that to provide compassionate care we need to know the details of care that matter to the person (Burnell & Agan 2013, Health Foundation 2014). Information captured through WMTY provides staff with a unique knowledge of the person, which then informs the plan of care for that patient. It is recorded on the WMTY board, which is kept at the bedside, or as determined by the patient, for ease of access by all healthcare professionals. The IHF “What Matters to Me” education programme has been adapted for use in the acute hospital to support this initiative. A suite of documents were developed to provide guidance and information, thus supporting the project’s implementation.References:1- Burnell, L., & Agan, D. Compassionate care : Can it be defined and measured ? The development of the compassionate care assessment tool. International Journal of Caring Sciences, 2013;6(2):180–187.2- Dewar, B., & Nolan, M. Caring about caring: Developing a model to implement compassionate relationship centred care in an older people care setting. International Journal of Nursing Studies, 2013;50(9):1247–1258.3- Doyle, C., Reed, J., Woodcock, T., & Bell, D. Understanding what matters to patients - identifying key patients’ perceptions of quality. JRSM Short Reports, 2010;1(1):3. Available from http://shr.sagepub.com/content/1/1/3.full.pdf+html 17th September 2016.4- Drayton, N., & Weston, K. Exploring values in nursing : generating new perspectives on clinical practice. Australian Journal of Advanced Nursing, 2015;33(1):14–23.5- Health Foundation. Person-centred care made simple: What everyone should know about person-centred care. Health Foundation. 2014.6- HSE. Service Plan. Health Service Executive. 2015.7- HSE. & Age Friendly Ireland. Listening to older people: Experiences of health services. Health Service Executive. 2015.8- Lown, B. A., Rosen, J., & Marttila, J. (). An agenda for improving compassionate care: A survey shows about half of patients say such care is missing. Health Affairs, 2011;30(9):1772–1778.9- NHS. Safe, compassionate care for frail older people using an integrated care pathway: Practical guidance for commissioners, providers and nursing, medical and allied health professional leaders. 2014. Available from: https://www.england.nhs.uk/wp-content/uploads/2014/02/safe-comp-care.pdf10- Shahin, A., & Mahbod, M. Prioritization of key performance indicators. International Journal of Productivity and Performance Management, 2007;56(3):226–240.11- von Dietze, E., & Orb, A. Compassionate care: a moral dimension of nursing. Nursing Inquiry, 2007;(3):166–174.

Background: This project was initially undertaken by the Department of Medicine for Older people in two Academic Teaching Hospitals in Dublin. It is led by two Clinical Nurse Specialists in Gerontology and is supported by geriatricians in both sites. It has recently gained the support of the Irish Hospice Foundation (IHF) Nursing Homes Ireland (NHI) and National Clinical Programme for Older People (NCPOP). Problem: Information sent from local nursing homes to the acute hospital Emergency Department often lacks the information required to provide safe quality care to the older person in an emergency situation. Hence, members of the interdisciplinary team spend inordinate amounts of time contacting these NH’s in order to obtain basic information that will support important care and treatment decisions in the acute setting for this complex, frail patient group. Information on medications, infection status, diet, cognition, functionality, advanced care planning are essential if we are to determine patient need. Assessment of problem and analysis of its causes: A prospective audit was carried out in 2011 to assess the problem outlined above in which 35 transfer letters from 29 different NHs were reviewed. A questionnaire was used to assess 24 aspects of information been received at the point of hospital entry. A template transfer letter was devised from the questionnaire to capture demographic information, baseline medical information, physical information and the cognitive status of the patient being transferred to hospital from each NH. The template was sent at the end of the audit period to all Directors of Nursing in each NH. All were requested to send feedback on the template so it could be modified for phase 2 of the project. Intervention: As a result of the consultative process a new transfer document was developed. Support from the national advisory body Nursing Homes Ireland (NHI) was ascertained. In order to enhance accessibility and promote usage, the document was made available on both hospital websites and a care planning database ‘Epicare’ which is used by 60% of NH’s nationally. Strategy for change: From the outset of the project in 2011, we consulted with Directors of Care from NH’s through NHI; in order to ascertain that: 1) the proposed content of the Transfer letter was appropriate and, 2) that updates on the transfer document were communicated to reflect national standards / guidance. Measurement of improvement: Continuous audit cycles (4) and on-going consultation with NH’s; allowed us measure improvements in the quality of transfer information. In 2015, 62% of NH were using the standardised template document (n=37) a decrease from 73% in 2012. However, baseline demographic & medical information was well documented, as were Functional Scores (90-100%). Other Results show improvements & areas for concern Effects of changes: Improvements in transfer communication meant clinicians in Acute Hospitals (AH)’s and NH’s spent less time looking for information deemed vital to patient care. One of the challenges was that NH’s wanted more information on the document at each stage of the consultation process. Its’ success as a single page document at local level allowed the document to trialled at regional level with funding support from the IHF. 189 NH’s were contacted and 83% (81 replies) used the document and reported it to be useful and comprehensive. Lessons learnt: The document is currently undergoing an integrated consultation process between both the NH & AH Sectors for National application with the support of NCPOP. Other stakeholders challenge its single page status and its’ scope has been be broadened to include other areas of the residential care sector. Quality of transfer information from AH to NH will need to be considered following this phase as requested by NH’s. Messages for others: A single page document with key information that represents patient need is vital during transitions of care. It helps reduce incidences of missed care through the provision of appropriate information between healthcare stakeholders. Consultation with Directors of Care or Clinicians from both NH & AH respectively is essential on behalf of NH patients to ensure that the information been transferred is satisfactory and that patient need is been met through appropriate transfer of information when developing or using a standardised template.

Background: Population ageing is causing important and fundamental changes for health and social care services nationally and internationally. Many people remain well, engaged and active into later life and continue to make a major contribution to local communities and society. However increasing age also brings an increasing chance of long-term medical conditions, frailty, dementia, disability, dependence or social isolation. Life expectancy at age 75 increased by 29% (female) and 39% (males) between 1993 and 2013 (Eurostat 2014) and the number of people over 80 in Ireland will doubled in the next ten years (CSO 2011). People aged 65 and over now constitute 11.7% of the population and use 61%% of acute hospital inpatient bed days (HIPE 2014). The growing older population has consequences for the nursing profession and for nurse education. An increasing demand for nurses to work with older people over a wide range of services including hospitals, residential care, health and community services is inevitable. If nurses are to gain a holistic perspective and expertise in this specialist area of care, their preparation and ongoing professional development will need to focus on the competencies required for working with older people.Therefore, nurse education and curricula need to be responsive to the diverse and holistic needs of older people and changing care environments. It is imperative that the future of gerontological nurse education is designed to equip nurses with the knowledge skills and competencies necessary to meet those needs. Project: While the Clinical Strategy & Programmes Division seek to implement models of care (HSE 2012), a parallel vision for the future of gerontological nursing is necessary to ensure we provide age attuned services into the future. The National Clinical Programme for Older People (NCPOP) in collaboration with the Office Nursing Midwifery Services Directorate (ONMSD) are developing a strategic vision and educational framework for nurses working with older people across the spectrum of healthcare. The aim of this work is to develop a nursing service that has the knowledge, skills and competencies to meet the needs of the older population into the future. The proposed framework will incorporate a vision for gerontological nursing to include career pathways and the competencies and educational requirements required to effectively fulfil these roles. The methodology applied by the National Cancer Control Programme has been replicated to inform and direct this body of work. In 2016 a systematic literature review was undertaken by the McAuley School of Nursing & Midwifery, University College Cork, to inform the development of an educational framework to enable nurses to acquire and maintain the necessary knowledge, skills and competence, at the appropriate level to deliver quality person centred care to older people, throughout the Irish health service.The second part of the methodology was the completion of a number (n=5) national focus groups with relevant stakeholders which will included older people, healthcare professionals, educators, policy makers, carers and other interested parties (n=280). The overall research question to be answered is “What knowledge, skill and competence are required to produce a nursing workforce that can provide quality person centred care to older people wherever they access healthcare? The final framework document will be completed in November 2017

Introduction: Although not an inevitable part of ageing, frailty is an increasingly common condition in older people (Savva et al., 2013). The associated potential for serious adverse outcomes means that even a relatively minor event such as an infection can result in a dramatic change in health status: from independent to dependent; mobile to immobile; postural stability to falling; lucid to delirious (Clegg, 2013). Furthermore, frailty has been shown to be a strong and independent predictor of emergency department visits and hospitalisations, hospital readmissions (Pugh et al., 2014) and in-hospital mortality (Bagshaw et al. 2013). Healthcare professionals need to understand the risk factors for frailty to enable them to implement effective programmes for detection, prevention and management. Frailty: What We Know The recognition of frailty is important and should form part of any interaction between an older person and a healthcare professional. An individual’s degree of frailty is not static. It may improve or deteriorate, and is influenced by factors including the care received when an individual presents to a health professional. One of the major challenges posed by an ageing population is the ability of healthcare professionals to understand, recognise and manage frailty Programme Aim: Frailty is an emerging science and this programme was developed to provide healthcare professionals with the knowledge and skills required to provide effective care to older people living with frailty, wherever they access health services. It aims to provide healthcare professionals with an enhanced understanding of frailty and frailty assessments, thereby ensuring earlier recognition , improved healthcare management and better health outcomes for frail older adults. The programme philosophy is based on the belief that education increases knowledge and enhances healthcare professional’s skills in the clinical area. Methodoogy: The National Frailty Education Programme (NFEP) is a collaboration between NCPOP and The Irish Longtitudinal Study on Aging (TILDA), in partnership with the Acute and Emergency Medicine Programmes. Using a "proof of concept" design the programme is being piloted in three Hospital Groups and corresponding Community Healthcare Organisations. The programme methodology involves: Step 1: Nominated facilitators from participating hospitals and CHOs attend a one day ”Insights into Frailty” education Programme with TILDA. These nominees are representitive of all members of the multidisciplinary team. Step 2: This group attend a one-day workshop with the NCPOP Step 3: These facilitators roll-out the NFEP in an integrated manner across their local organisation. Parallel to this a local governance group is established to support the programme roll-out and to consider new ways of working that will enhance outcomes for the frail older person accessing their services Evaluation: Survey of facilitators knowledge pre and post TILDA Analysis of NFEP participants learning Service outcome evaluation may include: implementation of an assessment tool, audit of the use of the chosen tool, documented referral pathways, initiation of CGA and audit of numbers undertaken. Further examination of impact may involve decreased length of stay, reduction in falls, and audit of delirium management. All outcome measures would be aligned to the NCPOP KPI’s and national strategy.

Rationale for Training: Population ageing is occurring rapidly and between 2015 and 2050, the number of people aged 60 years and older is expected to increase from 12% of the global population to 22% (WHO, 2012). In Ireland, currently 13% of the population is 65 years or older and this number is expected to double by 2040 (Central Statistics Office, 2008). As older people have different healthcare requirements, the Irish healthcare system needs to adapt to meet the demands associated with this demographic change. Healthcare spending in Ireland is expected to rise from 5.8 to 6.7% of GDP by 2035 (European Commission, 2009). Almost 22% of all hospital emergency department attendees are aged 65 and over and this age group account for 40% of all acute emergency medical admissions and 47.3% of total hospital bed days (HSE, ED Task Force Report, 2015, NCPOP, 2012). One of the greatest challenges posed by an ageing population is the ability of healthcare professionals to understand, recognise and manage frailty. Frailty: Frailty is theoretically defined as a clinically recognisable state of increased vulnerability resulting from age-associated decline in reserve and function across multiple physiologic systems (Qian-Li Xue, 2011). Frailty affects approximately 8-10% of people over the age of 65 and 25-50% of those aged 85 and over (Mytton et al., 2012; Collard et al., 2012; Savva et al., 2013). Although frailty is an increasingly common condition in older people, it is not an inevitable part of ageing and in some cases it can be treated or prevented depending on its underlying cause. A lack of consensus regarding the operational definition of frailty makes it difficult to identify and manage in clinical practice (Rodriguez-Manas, et al., 2013). However, conceptualizing frailty as a continuum from not frail, to pre-frail, to frail is considered a valid way to identify subgroups of older adults at risk of adverse outcomes such as falls, worsening disability, prolonged hospitalization and death (Clegg & Young, 2015). The potential for serious adverse outcomes is a central problem associated with frailty. For people with frailty even a relatively minor event such as an infection can result in a dramatic change in health state: from independent to dependent; mobile to immobile; postural stability to falling; lucid to delirious (Clegg, 2013). Further to this, frailty has been shown to be a strong and independent predictor of emergency department visits and hospitalizations (McNallan et al., 2013), hospital re- admissions (Pugh et al., 2014) and in-hospital mortality (Bagshaw et al., 2013). Unplanned admissions to hospital in an emergency situation can be both distressing and disruptive for frail older people, their families and carers. These admissions create rising demands on acute hospital beds and result in enormous costs to Ireland’s health service. Therefore, this topic has relevance for policy makers, clinicians and nursing staff who need to understand the risk factors for frailty to enable them to implement programmes for early detection, prevention and management. By increasing awareness and understanding of frailty, we can improve outcomes for these older adults and reduce demands on the health service. Methodology: It is proposed that the methodology applied to the implementation of the National Early Warning Score would be applied to the roll out of a frailty education programme. This includes: - Providing a training programme for a cohort of national trainers (N= to be agreed) who will: - Provide local education programmes - Maintain a database of locally trained staff - Lead local governance group Establishment of National Steering Group (incl. cohort of national trainers, and nominated stakeholders) to: - Develop an educational programme for delivery locally - Develop a framework for interdisciplinary education - Develop an e-learning programme The Longtitudinal Study on Aging (TILDA): Using cutting edge research and the unique resources at the TILDA Health Assessment Centre in Trinity College, TILDA will deliver a one-day training course to nurses interested in learning more about frailty. The course will incorporate key research findings from TILDA, provide an overview of the theoretical models underpinning frailty and include training in key frailty assessment tools. Nurses are an integral part of the collaborative approaches to services for patients with frailty. This training will encourage nurses to be proactive members in the early identification and assessment of frailty, ensuring effective management to improve outcomes for these vulnerable adults.

This paper describes an investigation into the aetiology of a variety of recurrent oral lesions in the adult, with the result that an unidentified organism was repeatedly demonslrated in sections of chorioallantoic membranes (CAMs) inoculated with 17 specimens of curetted tissues from recurrent oral lesions. The organism is a strict parasite which grows well in the CAMs of the developing hen"s egg, where it is seen to undergo growth phases of a complex nature. In the intracellular phases it may be mistaken for a virus or a rickettsia, in the extracellular phases for a bacterium or a protozoan. Pox are produced on the CAMs and haemorrhages and death occur in the embryos during the intracellular phases. The virulence of the organism increases with serial passage, with the production of a haemolytic toxin and 100% mortality rate. In tissue cultures the medium was rapidly metabolized and cytopathogenic effects occurred. Hanging drop preparations showed motility of a rapid, spinning, tumbling nature. The organism will not grow on a variety of enriched acellular media under aerobic or anaerobic conditions. It stains well with Giemsa"s stain but poorly with Gram"s. It is insensitive to large doses of penicillin and streptomycin. Guinea pigs and rabbits may be infected with the fresh primary material. CAM antigens do not fix complement in the presence of homologous serum or herpes simplex antisera. We have not been able to identify the organisms.