The behavior and welfare of neglected species: some examples from fish and mammals.

Animal welfare is the state of an animal's body and mind and the level to which its requirements are satisfied. Animal welfare is affected by human decisions and actions. Numerous decisions concerning animals are driven by human desires to enhance their own lives, and some of these decisions may be influenced by self-interest or a strong emphasis on economic factors. How to assess the welfare state of animals is a central issue in animal welfare science. Two critical questions can be used to address animal welfare: first, is the animal healthy, and second, does the animal have what it needs? Both of these questions can potentially be answered using the study of animal behavior. The development of behavioral methodologies is crucial for evaluating welfare in contexts where concern for animal welfare is often highest, such as on intensive modern farms and sites where working animals are used. Herein, we discuss animal welfare by focusing on some of its major concepts and explanations. Later, to illustrate key aspects of animal welfare, we chose to examine the information that is available for some 'neglected' livestock species, which are commercially important on a global basis and found in large numbers: buffaloes (Bubalus bubalis), camels (Camelus dromedarius), donkeys (Equus asinus), mules (Equus asinus × Equus caballus), and lumpfish (Cyclopterus lumpus). We chose these species because there are major ongoing concerns about their welfare, and more research is required to help solve the various problems. Overall, there are strong imbalances in terms of the species that are usually studied in terms of animal welfare research, and we call for greater attention to those that have traditionally been neglected.

Associations between Racing Thoroughbred Movement Asymmetries and Racing and Training Direction.

BACKGROUND: Racehorses commonly train and race in one direction, which may result in gait asymmetries. This study quantified gait symmetry in two cohorts of Thoroughbreds differing in their predominant exercising direction; we hypothesized that there would be significant differences in the direction of asymmetry between cohorts. METHODS: 307 Thoroughbreds (156 from Singapore Turf Club (STC)-anticlockwise; 151 from Hong Kong Jockey Club (HKJC)-clockwise) were assessed during a straight-line, in-hand trot on firm ground with inertial sensors on their head and pelvis quantifying differences between the minima, maxima, upward movement amplitudes (MinDiff, MaxDiff, UpDiff), and hip hike (HHD). The presence of asymmetry (≥5 mm) was assessed for each variable. Chi-Squared tests identified differences in the number of horses with left/right-sided movement asymmetry between cohorts and mixed model analyses evaluated differences in the movement symmetry values. RESULTS: HKJC had significantly more left forelimb asymmetrical horses (Head: MinDiff p < 0.0001, MaxDiff p < 0.03, UpDiff p < 0.01) than STC. Pelvis MinDiff (p = 0.010) and UpDiff (p = 0.021), and head MinDiff (p = 0.006) and UpDiff (p = 0.017) values were significantly different between cohorts; HKJC mean values indicated left fore- and hindlimb asymmetry, and STC mean values indicated right fore- and hindlimb asymmetry. CONCLUSION: the asymmetry differences between cohorts suggest that horses may adapt their gait to their racing direction, with kinematics reflecting reduced 'outside' fore- and hindlimb loading.

Assessing the impact of draught load pulling on welfare in equids.

About 112 million working equids are the source of income for 600 million people globally. Many equids are used for pulling loads (up to 15,000 kg per day) to transport goods. Most of them are associated with brick kilns, mining, and agriculture industries in developing countries. They may suffer from welfare issues such as overloading, being beaten, and being forced to work for long periods. These issues may occur due to a poor understanding of load-pulling equids. Understanding their capabilities and the elements that influence them is critical for efficient performance and welfare. The measurement of stride characteristics and gait kinematics can reveal loading adaptations and help identify loading limitations. It is known that both loading and fatigue change the locomotor patterns of load-pulling horses. Heart rate is a stress quantifying metric and an important representative of the speed of work and draught force. Heart rate variability is a regularly used statistic to quantify a physiological response to stresses, but it has never been used for load-pulling equids. Changes in blood lactate, nitrogen, oxygen, and carbon dioxide contents are reliable biochemical indicators of the effects of load pulling. Changes in plasma cortisol levels reflect the intensity of exercise and stress levels in horses while pulling a load. However, eye blink rate is a cheap, simple, and immediate indicator of acute equine stress, and we suggest it may be used to aid in load-pulling equine welfare assessment. However, further research is needed for a standardized and evidence-based draught load pulling capacity of working horses, mules, and donkeys.

Recognition of emotion and pain by owners benefits the welfare of donkeys in a challenging working environment.

Working donkeys (Equus asinus) support human living standards globally. However, there is little information on the effect of human perceptions of emotion and pain on the welfare of working donkeys. We interviewed donkey owners (n = 332) in Pakistan to determine the relationship between human perspectives on donkey sentience: emotions and the ability to feel pain, and the routine working practices that could impact donkey welfare. The majority of donkey owners used padding under the saddle (n = 211; 63.6%; 95% CI (58.3%-68.9%)) and provided access to food (n = 213; 64.2%; 95% CI (58.9%-69.3%)) and water (n = 195; 58.7%; 95% CI (53.4%-64.1%)) during the working day. Owners reported that at some point in their donkey's life, 65.3% (95% CI (60.2%-70.5%)) had load-associated injuries, of which 27.7% (n = 92; 95% CI (22.8%-32.5%)) were wounds, 20.5% (n = 68; 95% CI (16.1%-24.8%)) were lameness and 7.2% (n = 24; 95% CI 4.4%-10.0%) were back pain. In total, 81.3% (95% CI 77.1%-85.5%; n = 270) of owners believed that their donkeys felt pain, and 70.2% (95% CI (65.2%-75.1%; n = 233) of owners believed that their donkeys had emotions. Multiple correspondence analysis (MCA) was used to understand the relationship between owners' recognition of emotions and pain in donkeys and their working practices. The MCA factor map revealed two clusters, named positive and negative clusters. The positive cluster included owner's recognition of donkey pain and emotions, the availability of food and water, use of padding under the saddle, absence of injuries along with the willingness to follow loading guidelines. The negative cluster represented practices that did not benefit donkey welfare, such as using saddles without padding and a lack of food and water during work. The presence of injuries, owners not recognizing that donkeys feel pain and emotion along with an unwillingness to follow loading guidelines were also found in the negative cluster. We show that the owners who recognized sentience in their donkeys were more likely to use practices that are good for donkey welfare. The ability of owners to identify sentience in donkeys, along with their willingness to follow welfare guidelines, are important factors in improving the lives of working donkeys.

Hoof morphometry in a population of lame and nonlame working donkeys in Pakistan.

BACKGROUND: Hoof morphometry, conformation and shoeing practices have all been associated with lameness in horses. Hoof morphometry in working donkeys in Pakistan has not been objectively measured. OBJECTIVES: To quantitatively assess hoof morphology in donkeys, to identify factors underlying hoof morphology, and interrelationships between conformation, lameness, and shoeing status. STUDY DESIGN: Cross-sectional study. METHODS: Donkeys were assessed in-harness using a modified five-point lameness scale by two veterinarians and digital photographs of front hooves taken alongside a grid. Factor analysis was used to examine the interrelationships among morphometric data. Associations between conformation, shoeing, age and lameness were assessed. RESULTS: Sixty-one donkeys were examined; 28 were unshod. There were significant left-right hoof asymmetries between heel height (0.27, SD 0.92 cm; p = 0.02), toe-heel angle (2.97°, SD 8.85°; p = 0.03) and medio-lateral symmetry (0.5, SD 1.75 cm; p = 0.05). Ten percent of donkeys (n = 6) were sound and 64% donkeys (n = 39) were consistently lame. Conformational defects were seen in 41% (n = 25) of donkeys. Eleven factors were extracted, accounting for 83% of the variance encountered in the original variables. Shoeing, and asymmetry between or within feet were not associated with lameness in donkeys; older donkeys were more likely to be lame (p = 0.02). MAIN LIMITATIONS: As a convenience sample of draught donkeys, most of which were lame, the study may not reflect nonpathological hoof morphology in working donkeys. There are no validated objective lameness measures for donkeys and donkeys were in harness when assessed. CONCLUSION: This study represents a snapshot of hoof morphology and lameness in a single population and under various limitations. Further work should use larger datasets and more homogenous samples to discriminate between 'normal' and 'abnormal' feet and how these might contribute to lameness. Factor analysis highlighted the clustering of hoof morphometric features in donkeys, suggesting the potential for targeted studies in the future.

Serotype Diversity and Antimicrobial Resistance Profile of Salmonella enterica Isolates From Freshwater Turtles Sold for Human Consumption in Wet Markets in Hong Kong.

Chelonians are recognized as a source of human salmonellosis through direct contact or consumption of their meat. Freshwater turtles sold for food are widely available in wet markets in Asia. In this pilot study, 50 turtles belonging to three species were randomly sampled from wet markets throughout Hong Kong. The turtles were humanely euthanised and their feces or the colon were sampled for Salmonella culture. The Salmonella isolates obtained were serotyped and examined for phenotypic antimicrobial resistance and the presence of antimicrobial resistance genes. The study reports a high prevalence (42%, 95% CI: 29.4-55.8) and considerable serotype diversity of Salmonella among turtles sold in wet markets. The most common among the 11 serotypes isolated were S. Oranienburg and S. Thompson, which have been reported in turtles previously. The serotype S. Manhattan is reported in chelonians for the first time. Resistance to streptomycin and chloramphenicol was common, despite the latter being banned from aquaculture in mainland China since 2002. Resistance against fluoroquinolones and third-generation cephalosporins which represent first-line treatment options for salmonellosis was also observed. The multidrug-resistance gene cfr is identified for the first time in Salmonella. This is a worrying finding as it indicates an expansion of the cfr reservoir and potential horizontal spread to other bacteria. The results of this study emphasize the need for close surveillance of Salmonella from turtles sold as food and better regulation of turtle farming to safeguard public health and improve animal welfare.

Active learning for an evidence-based veterinary medicine course during COVID-19.

Epidemiology is often a challenging course that is not well appreciated by many students learning veterinary medicine. The curriculum for this topic can sometimes be dry, difficult for students to contextualize, and heavy with statistics and mathematical concepts. We incorporated the concepts of epidemiology that are most important for practicing veterinarians and combined these with evidence-based veterinary medicine principles to create a practical course for second-year undergraduate veterinary students. We share the structure of our course and the different learning components, which also included incorporating graduate student mentors for journal clubs and an assignment that culminated in some students publishing their review findings. Anecdotal responses from students suggest they enjoyed the course and learned skills they felt would be useful in veterinary practice to help them make evidence-based clinical decisions.

Welfare Concerns for Mounted Load Carrying by Working Donkeys in Pakistan.

Working donkeys (Equus asinus) are vital to people's livelihoods. They are essential for carrying goods, however, globally, overloading is one of the primary welfare concerns for working donkeys. We studied mounted load carrying by donkeys and associated factors in Pakistan. A cross-sectional study of donkey owners (n = 332) was conducted, and interviews were undertaken based on a questionnaire. Owners estimated that the median weight of their donkeys was 110 kg [interquartile range (IQR) 100-120 kg], and that they carried a median mounted load of 81.5 kg (IQR 63-99 kg). We found that 87.4% of donkeys carried a load above 50% of their bodyweight ratio (BWR), the median BWR carried was 77.1% (IQR 54.5-90.7%), and 25.3% of donkeys carried above 90% BWR. Donkeys that were loaded at more than 50% BWR were more likely to adopt sternal recumbency compared to donkeys loaded with less weight (P = 0.01). Donkeys carrying construction material were more likely to carry more than the median BWR, when compared to domestic loads (P < 0.001). Younger donkeys aged between one and 5 years carried more than the median BWR compared to those aged over 15 years (P = 0.03). For the models with donkeys carrying median BWR and above 90% BWR, those working in peri-urban and urban areas were more likely to carry a greater BWR than donkeys working in rural areas (P < 0.001; P < 0.001, respectively). For donkeys carrying more than 90% BWR, mixed breed donkeys carried higher loads compared to other breeds of donkeys (P < 0.001). Overloading based on current recommendations (50% BWR) was common, with the majority (87.4%) of donkeys reported to carry more than the recommended 50% limit. This survey provides evidence of on-the-ground working practices and factors associated with mounted load carrying, which is critical for developing evidence-based recommendations for loading, in order to improve the welfare of working donkeys.

Cross-Sectional Questionnaire of Donkey Owners and Farriers Regarding Farriery Practices in the Faisalabad Region of Pakistan.

Quality farriery is essential to ensure donkey welfare, and many intervention programs in low-middle income countries (LMICs) train farriers, and educate owners, regarding the farriery needs of donkeys. It is essential for interventional programs to understand the perspectives of all stakeholders in donkey-owning communities. A cross-sectional questionnaire study was conducted in the Faisalabad region of Pakistan. Ten farriers and 55 donkey owners participated in the study. Farriers reported receiving no formal training for farriery, insufficient wages (PKR 65 or USD 0.36 per hoof) and the requirement to use traditional tools. Farriers reported an average shoeing time of 5 min per hoof and shoeing between three and 30 donkeys a day. Donkeys were mostly shod while they were harnessed to a cart. Six donkey-owning farriers reported shoeing their donkeys every 20 to 25 days. Owners reported varying shoeing intervals of 20 days to 90 days. Shoeing interval was also affected by seasonal and weather changes. Owners considered their relationship with farriers as the most important factor in choosing a farrier rather than cost. A majority (87%) of the owners reported lameness in their donkeys. The study provides important insights into the many challenges and opportunities in developing quality donkey farriery in the region.

Cross-Modality Interaction Network for Equine Activity Recognition Using Imbalanced Multi-Modal Data.

With the recent advances in deep learning, wearable sensors have increasingly been used in automated animal activity recognition. However, there are two major challenges in improving recognition performance-multi-modal feature fusion and imbalanced data modeling. In this study, to improve classification performance for equine activities while tackling these two challenges, we developed a cross-modality interaction network (CMI-Net) involving a dual convolution neural network architecture and a cross-modality interaction module (CMIM). The CMIM adaptively recalibrated the temporal- and axis-wise features in each modality by leveraging multi-modal information to achieve deep intermodality interaction. A class-balanced (CB) focal loss was adopted to supervise the training of CMI-Net to alleviate the class imbalance problem. Motion data was acquired from six neck-attached inertial measurement units from six horses. The CMI-Net was trained and verified with leave-one-out cross-validation. The results demonstrated that our CMI-Net outperformed the existing algorithms with high precision (79.74%), recall (79.57%), F1-score (79.02%), and accuracy (93.37%). The adoption of CB focal loss improved the performance of CMI-Net, with increases of 2.76%, 4.16%, and 3.92% in precision, recall, and F1-score, respectively. In conclusion, CMI-Net and CB focal loss effectively enhanced the equine activity classification performance using imbalanced multi-modal sensor data.

How Do You Be Your Best Self in a Vexatious World?

How do we survive, let alone thrive, in health care? The complexity of providing care to patients and families on chronic kidney replacement therapy can be taxing for the most expert and resilient of health care professionals. Further complicating this by a global pandemic can produce feelings of frustration and anxiety that can reduce our effectiveness in the everyday, yet we are compelled to practice competently and professionally. Working on oneself is key to optimizing one's resilience during volatile, uncertain, complex, and ambiguous times. This article introduces the concept of emotional intelligence and provides a brief review of the brain science behind behavioral patterns, highlighting how all health care professionals can engage in self-work to bring our best selves to the every day.

Quantifying the Impact of Mounted Load Carrying on Equids: A Review.

There are approximately 112 million working equids in developing countries, many of which are associated with brick kilns. Brick kilns and overloading are associated with welfare problems in working equids. Understanding equids' abilities and influencing factors are important for both effective performance and welfare. Traditionally, measurement of the amount of 'bone' was used, and more recently, gait symmetry has been identified as a potential marker for loading capacity. Assessment of stride parameters and gait kinematics provides insights into adaptations to loading and may help determine cut-off loads. Physiological factors such as the ability to regain normal heart rates shortly after work is an important tool for equine fitness assessment and a more accurate measure of load-carrying capacity than absolute heart rate. Oxidative stress, plasma lactate, and serum creatine kinase activity are reliable biochemical indicators of loading ability. For monitoring stress, salivary cortisol is superior to serum cortisol level for assessment of hypothalamus-pituitary-adrenal axis and is related to eye temperatures, but this has yet to be interpreted in terms of load-carrying ability in equids. Further research is needed to standardize the evidence-based load-carrying capacity of working horses and donkeys.

Interaction Identified as both a Challenge and a Benefit in a Rapid Switch to Online Teaching during the COVID-19 Pandemic.

The recent emergence and subsequent global spread of COVID-19 has forced a rapid shift to online and remote learning at veterinary schools. Students in a Bachelor of Veterinary Medicine program were taught using a real-time online platform for one semester, with recorded synchronous lectures and tutorials, virtual laboratories, and clinical skills classes where possible. Students in all years of the program were surveyed twice, 8 weeks apart to assess their perceptions of online teaching and to identify challenges they experienced. Using a 10-point Likert scale, students agreed that they could achieve their learning outcomes using online learning with no more difficulty than with face-to-face teaching, allocating average scores of 7.6 and 8.2 at each time point. Students were overwhelmingly positive about the impact of online teaching on time-management of their learning due to the loss of travel time. They enjoyed aspects of teaching such as recorded lectures, online polls quizzes, and chat boxes that allowed more student-focused learning. However, there were concerns about the reduction in face-to-face interactions including loss of classroom atmosphere and reduced interaction with peers. Students experienced technical problems in a median of 20% of lectures (range 10%-50%) at the first survey and 10% at the second (range 10%-50%). Increased use of strategies to optimize peer interactions is recommended to facilitate student learning using online platforms. Moving forward beyond the pandemic, allowing flexible time management and a shift toward student-centered learning using strategies such as flipped classrooms may be beneficial.

The effect of curve running on distal limb kinematics in the Thoroughbred racehorse.

During racing, injury is more likely to occur on a bend than on a straight segment of track. This study aimed to quantify the effects of galloping at training speeds on large radius curves on stride parameters and limb lean angle in order to assess estimated consequences for limb loading. Seven Thoroughbred horses were equipped with a sacrum-mounted inertial measurement unit with an integrated GPS, two hoof-mounted accelerometers and retro-reflective markers on the forelimbs. Horses galloped 2-4 circuits anticlockwise around an oval track and were filmed at 120 frames per second using an array of ten cameras. Speed and curve radius were derived from GPS data and used to estimate the centripetal acceleration necessary to navigate the curve. Stride, stance and swing durations and duty factor (DF) were derived from accelerometer data. Limb markers were tracked and whole limb and third metacarpus (MCIII) angles were calculated. Data were analysed using mixed effects models with a significance level of p < 0.05. For horses galloping on the correct lead, DF was higher for the inside (lead) leg on the straight and on the curve. For horses galloping on the incorrect lead, there was no difference in DF between inside and outside legs on the straight or on the curve. DF decreased by 0.61% of DF with each 1 m s-2 increase in centripetal acceleration (p < 0.001). Whole limb inclination angle increased by 1.5° per 1 m s-1 increase in speed (p = 0.002). Limb lean angles increase as predicted, and lead limb function mirrors the functional requirements for curve running. A more comprehensive understanding of the effects of lean and torque on the distal limb is required to understand injury mechanisms.

The Effect of Training on Stride Duration in a Cohort of Two-Year-Old and Three-Year-Old Thoroughbred Racehorses.

Objective gait monitoring is increasingly accessible to trainers. A more comprehensive understanding of 'normal' gait adaptations is required. Forty two-year-old thoroughbred racehorses were recruited when entering training and followed for 22 months. Gait analysis was performed by equipping each horse with an inertial measurement unit with inbuilt GPS (GPS-IMU) mounted on the dorsum. Horses were exercised as per their regular training regimen. Data were analysed using a linear mixed model. For two-year-old horses, there was a non-linear pattern of stride duration (SD) over time (p < 0.001) with SD decreasing initially and then 'flattening off' over time (linear and quadratic coefficients -0.29 ms/week and 0.006 ms/week2). Horses showed an increase in SD of 2.21 ms (p < 0.001) per 100 m galloped, and over time, SD decreased by 0.04 ms (p < 0.001) with each 100 m galloped per week. Three-year-old horses overall showed no change in SD over time (p = 0.52), but those that had a period of time off showed a decrease in SD of -0.59 ms per week (p = 0.02). They showed an increase in SD of 1.99 ms (p < 0.001) per 100 m galloped, and horses that had a period of time off showed an increase in stride duration of 1.05 ms per 100 m galloped (p = 0.01) compared to horses which did not have time off. Horses demonstrate an adaptation to high-speed exercise over time. SD decreases with training when other factors are controlled for in naïve horses.

Is there an association between clinical features, response to diagnostic analgesia and radiological findings in horses with a magnetic resonance imaging diagnosis of navicular disease or other injuries of the podotrochlear apparatus?

Previous descriptions of the clinical features of navicular disease occurred before the widespread use of magnetic resonance imaging (MRI) allowed a more definitive diagnosis of foot pain. The objective of this study was to compare the clinical features of horses with lesions of the podotrochlear apparatus with those with other causes of foot pain. It was hypothesised that primary navicular bone disease would be associated with more advanced radiological findings than other diagnoses. A retrospective study was performed of all horses examined at a referral centre with a definitive diagnosis of foot pain based on MRI ± post-mortem examination. Clinical examination findings, response to diagnostic analgesia and radiological grading of the navicular bone were compared among five diagnosis groups: (1) primary navicular bone pathology (NB); (2) lesions of the collateral sesamoidean ligament and/or distal sesamoidean impar ligament (CSL + DSIL); (3) primary deep digital flexor tendon injury (DDFT); (4) navicular bone pathology and other lesions of the podotrochlear apparatus ± DDFT (PTA) and (5) Other. There were 702 horses (NB, 62; CSL + DSIL, 180; DDFT, 69; PTA, 92; Other, 299). Horses with PTA injuries were more frequently unilaterally lame than other groups (P = 0.04). Horses with DDFT injury were more likely to exhibit pain on turning than other groups (P <0.01). There were no associations between response to diagnostic analgesia and diagnostic group, and no association between radiological grade and diagnostic group. Clinical examination findings generally did not discriminate between diseases of the PTA and other causes of foot pain. Overall radiological scores of the navicular bone did not accurately predict navicular bone pathology.

An investigation of risk factors for foot-related lameness in a United Kingdom referral population of horses.

Lameness relating to the foot of the horse is common, but the majority of information concerning risk factors for injury is anecdotal. The objectives of this study were to investigate risk factors for foot-related pain in a referral population of horses, with particular reference to injury/disease of the podotrochlear apparatus (PTA), by comparison with the remainder of the clinic population. It was hypothesised that there would be an increased risk of foot pain associated with breed, work discipline, age, height and bodyweight (BW). A retrospective study of all horses examined at a referral centre between 2001 and 2010 was performed using univariable and multivariable logistic regression analyses. There were 4618 horses investigated, 1132 of which had foot pain. There was increased risk of foot pain in multivariable analyses (all categories combined) in horses aged 6-9 and 10-15 years (OR = 1.60 and 1.72, respectively), compared with horses <6 years old, in show jumpers (OR = 1.44) compared with dressage horses, Thoroughbred cross-breeds (OR = 1.53) compared with Warmbloods and in horses with a BW:height ratio in the upper two quartiles (3.45-3.71 or >3.71; OR = 1.55 and 1.44, respectively), compared with the lowest quartile (<3.19). Racehorses had reduced risk for all types of foot pain combined (OR = 0.13) compared with dressage horses. Risk factors for PTA injury were age (10-15 years, OR = 2.12; >15 years, OR = 3.36, compared with <6 years old), BW:height ratio (>3.45-3.71 (OR = 2.75), >3.71 (OR = 2.06), compared with <3.19) and Thoroughbred cross-breed (OR = 1.73) compared with Warmbloods. Show jumpers had an increased risk of PTA and other injuries (OR = 2.29) when compared with dressage horses. Age, breed, work discipline and BW:height ratio influenced the risk of foot pain, but other factors probably also play a role.

A mixed reality simulator for feline abdominal palpation training in veterinary medicine.

The opportunities for veterinary students to practice feline abdominal palpation are limited as cats have a low tolerance to being examined. Therefore, a mixed reality simulator was developed to complement clinical training. Two PHANToM premium haptic devices were positioned either side of a modified toy cat. Virtual models of the chest and some abdominal contents were superimposed on the physical model. The haptic properties of the virtual models were set by seven veterinarians; values were adjusted while the simulation was being palpated until the representation was satisfactory. Feedback from the veterinarians was encouraging suggesting that the simulator has a potential role in student training.

Leading complex change in healthcare: 10 lessons learned.

This article reports on the transfer of perinatal services at St. Joseph's Health Care, in London, Ontario, to London Health Sciences Centre (LHSC). The transfer of perinatal programs, services and people/providers to LHSC generates concern in key stakeholders with respect to a potential negative impact on the quality of care delivery, staff work life and morale, team performance, recruitment, retention and other performance indicators. Our main task was to establish "readiness and capacity for the change" in the years leading up to the actual transfer, with a strong focus on attending to the human side of the change, clinical and cultural alignment. We describe the external and internal challenges of the transfer and the approach that we took in building readiness, and end with 10 lessons learned and applied throughout the change process.