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Introduction: Psychotic disorders are strongly linked to a higher risk of mandatory hospitalization, often affecting men more, though some studies report the opposite. Recent investigations also show a higher rate of involuntary admissions in younger individuals. Knowledge in this area is still limited despite extensive research. Objectives: Analyze whether there is an association between sex and age with involuntary admissions of individuals with psychotic disorders. Methods: Retrospectively, 254 people with psychotic disorders admitted between 2018-2023 to the adult psychiatric inpatient unit at Hospital Universitari Germans Trias i Pujol were selected, collecting their nature of admission, sex, age, and discharge diagnosis. Comparisons between voluntary and involuntary admissions, with respect to sex and age variables, were conducted using independent sample t-tests, Mann-Whitney U tests, Fisher's exact test, and chi-square tests. A logistic regression model was used to identify variables significantly associated with mandatory admission. Results: In both the male and female groups, there were no statistically significant differences in terms of the mean age at admission (p = 0.162) or the nature of admission (p = 0.586) (Table 1). When analyzing the voluntary nature of admission based on age and sex, statistically significant differences were only found in the female group (p = 0.01), resulting in a 9.18 year age difference among those admitted voluntarily (Table 2). The model that best predicted the probability of involuntary admission in individuals with psychotic disorders included the sex variable (OR = 4.88) and the interaction between sex and age (OR = 0.97) (Table 3). Table 1: Differences between sex regarding voluntariness of patients with psychotic disorders. Male Female p value N (%) 122 (48%) 132 (52%) Age, m (SD) 38.39 (16.64) 44.15 (18.44) 0.162 Admissions, N (%) Voluntary 38 (31.1%) 37 (28.0%) 0.586 Involuntary 84 (68.9%) 95 (72.0%) Table 2: Analysis of voluntariness by sex and age. Age, m (SD) Voluntary Involuntary p value Male 37.45 (16.38) 38.81 (16.84) 0.677 Female 50.76 (18.19) 41.58 (17.98) 0.01* Total 44.01 (18.44) 40.28 (17.46) 0.127 Table 3: Predictors of involuntariness in psychotic patients: Logistic regression model (ENTER METHOD). Predictor -2log likelihood Nagelkerke R2 x2 (df*) OR* (95% CI*) p value 301.22 0.039 0.03 (1) Age 1.01 (0.98; 1.03) 0.674 Sex 4.88 (1.15; 20.72) 0.032* Age x Sex Interaction 0.97 (0.94; 0.99) 0.046* Conclusions: Young women with psychotic disorders face a higher risk of involuntary admissions, emphasizing the need for gender-specific strategies to improve care of these patients. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Diagnostic stability is a controversial issue in first episode psychosis (FEP) due to heterogenous symptoms and unclear affective symptoms. Differencing affective and non-affective psychoses is important as treatment strategies are different. Initial affective symptomatology has low specificity for predicting the subsequent diagnosis of affective psychosis. Sex has proven to be relevant for clinical and functional outcomes but it remains unclear how sex may contribute to diagnosis switch of FEP. Objectives: To determine the role of sex in diagnostic stability in a sample of FEP after 1-year follow-up. Methods: Diagnoses of FEP patients from Hospital del Mar of Barcelona were assessed at baseline and 1 year after. Univariate analyses was perfomed for all diagnoses and dichotomic variable (affective/non-affective). Logistic regression model was perfomed to know which variables predict diagnosis switch. Results: 256 patients were enrolled. No differences were found at baseline between completers and non-completers (Table 1).  No significant differences between men and women at baseline diagnosis were found, neither all diagnoses (p=0.274) nor the dichotomic variable affective/non-affective (p=0.829) (Table 2AB). Significant differences were found at 1-year follow-up between men and women, for all diagnoses (p=0.043) and the dichotomic variable (p=0.039). Sex was the only variable that predicted diagnosis switch  (Figure 1),  PANSS, CDSS, YMRS, GAF and cannabis did not. Table 1. Baseline characteristics of participants Completers (n=188) Non-completers (n=68) p Women (n, %) 71 (37.8) 30 (44.1) 0.111 Age (M, IQR) 24 (20-28) 22 (20-28) 0.899 Cannabis use (M, IQR) 5.5 (0-18) 7 (0-21) 0.231 DUP (M, IQR) 45 (12.5-130) 36 (11.25-115.75) 0.213 PANSS (m, sd) 44.55 (10.17) 40.93 (10.42) 0.761 CDSS (M, IQR) 2 (0-7) 3 (0-5.5) 0.199 YMRS (m, sd) 19 (9.64) 17.6 (9.15) 0.845 GAF (M, IQR) 30 (25-50) 30 (25-35) 0.114 TABLE 2A and 2B. Diagnosis comparison (n, %) Baseline 1-year follow-up Men Women Total Men Women Total Psychosis NOS 69 (59) 39 (54.9) 108 (57.4) 28 (23.9) 10 (14.1) 38 (20.2) Schizophreniform disorder 22 (18.8) 16 (22.5) 38 (20.2) 14 (12 9 (12.7) 23 (12.2) Induced psychosis 4 (3.4) 0 (0) 4 (2.1) 15 (12.8) 4 (5.6) 19 (10.1) Affective psychosis 17 (14.5) 9 (12.7) 26 (13.8) 24 (20.5) 25 (35.2) 49 (26.1) Schizophrenia 0 (0) 0 (0) 1 (0.4) 30 (25.6) 14 (19.7) 44 (23.4) Brief psychotic disorder 5 (4.3) 7 (9.9) 12 (6.4) 6 (5.1) 8 (11.3) 14 (7.4) Baseline 1-year follow-up Men Women Total Men Women Total Affective psychosis 17 (14.5) 9 (12.7) 26 (13.8) 24 (20.5) 25 (35.2) 49 (26.1) Non-affective psychosis 100 (85.5) 62 (87.3) 162 (86.2) 93 (79.5) 46 (64.8) 139 (73.9) Image: Conclusions: Sex has proven to be the main predictor of switching initial diagnosis of FEP. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Introduction: Obsessive-compulsive disorder (OCD) is a chronic disorder with a wide range of manifestations but primarily intrusive thoughts (obsessions) and/or ritualized actions (compulsions) that can cause a huge distress in patients' life. First-line treatment for OCD are selective serotonin reuptake inhibitors (SSRIs). Tricyclic antidepressants are used as second-line treatment due to secondary effects. Also antipsychotics such as aripiprazole are approved for treating OCD. Vortioxetine is has 5-HT3, 5-HT7 and 5-HT1D antagonists, 5-HT1B partial agonist and a 5-HT1A agonist and serotonin transporter inhibitor property. It is used in major depressive and anxiety disorders. A male 48 years old patient with an OCD diagnosis since he was 21, was reffered to psychiatry department. Previously, he had no response with SSRIs at full dosage and clomipramine 75mg was effective. At 46 years old, he had an acute myocardial infarction. He also admited not taking the medication regularly due to sexual disfunction and having affective symptoms related to the distress caused by OCD. Objectives: To evaluate efficacy of vortioxetine in treating OCD in a patient with contraindications for tricyclic antidepressants and no response to SSRIs. Methods: Clomipramine dose was reduced until discontinuation. After one week without treatment, basal scores for Hamilton Scale and Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) were collected. Same data was collected again after 10 weeks treatment. Results: The dosage of vortioxetine was progressively titrated until 20mg daily in 3 weeks lapse. Diazepam 5mg was added in case of insomnia or anxiety. Aripiprazole 5mg was added in the third week of treatment as adjunctive treatment due to the recurrence of some intrusive thoughts (discontinued by himself because of akathisia). Finally, the patient reported an improvement in affective and OCD symptoms in the sixth week of treatment that was sustained until the tenth week, when data was recollected. The patient did not refer sexual disfunction. The pre and post results are summarized in tables 1 and 2. Table 1. Hamilton Depresion Rating Scale (0-52) Basal Post 10-week treatment 21 4 Dimensional Y-BOCS (0-15) Basal Post 10-week treatment Aggressive-related obsessions and compulsions 10 2 Religious-related obsessions and compulsions 5 1 Symmetry and order 7 1 Pollution and cleaning 0 0 Collecting and accumulation 2 0 Miscellaneous 10 3 Conclusions: Vortioxetine might be a promising molecule for treating OCD in patients with contraindications for first and second-line treatments. Disclosure of Interest: None Declared [ABSTRACT FROM AUTHOR]

Deficits in functioning affect people with first-episode psychosis. Deficits in cognitive performance are common in such individuals and appear to be related to functioning. The present study examined the relationship between the domains of cognitive performance and personal and social functioning, as well as evaluating which cognitive domains are the most closely related to personal and social functioning and whether they explain variations once other clinical and sociodemographic aspects are accounted for. Ninety-four people with first-episode psychosis participated in the study; they were assessed with the MATRICS battery. Symptoms were evaluated with the Emsley factors of the positive and negative syndrome scale. Cannabis use, duration of untreated psychosis, suicide risk, perceived stress, antipsychotic doses, and premorbid intelligence quotient was accounted for. Processing speed, attention/vigilance, working memory, visual learning, reasoning and problem solving correlated to personal and social functioning. Processing speed emerged as the strongest predictor of social and personal functioning and underscores the importance of targeting this domain in treatment. Moreover, suicide risk and excited symptoms were also significant variables in functioning. Early intervention, focusing on improvement of processing speed, may be crucial to the improvement of functioning in first-episode psychosis. The relationship of this cognitive domain with functioning in first-episode psychosis should be studied further., Competing Interests: Declaration of competing interest The authors declare that there is no conflict of interest., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

People with a mental disorder have a higher risk of suicidal behavior. Little research has examined the role of childhood trauma in suicide behavior, and even fewer studies have assessed the specific relevance of subtypes of childhood trauma and suicidal behavior in first-episode psychosis (FEP). The aims of the present study were: 1) to compare suicide behavior between FEP and HC; 2) to study the relationship between the five types of ChT and suicide risk in FEP controlling for confounding sociodemographic, clinical, and psychosocial variables. 95 patients diagnosed with FEP and 92 healthy control (HC) were recruited as a part of the PROFEP study. ChT was evaluated using The Childhood Trauma Questionnaire-Short Form (CTQ) and suicide behavior through The Suicide Risk Scale of Plutchik (SRSP). Our results showed that patients with FEP presented more suicide behavior (ideation, attempt, and suicide risk) than HC. Emotional abuse was the most relevant type of ChT in suicide ideation and suicide risk. After controlling for other relevant variables, perceived stress seemed to play an important role in suicide ideations, suicide attempt, and suicide risk. The results highlight the importance of assessing and considering in the clinical practice ChT and the perceived stress., (Copyright © 2022. Published by Elsevier B.V.)

Providing the least restrictive mental health care is an unavoidable ethical principle and is one of the 10 basic prin- ciples of the “Mental Health Care Law” published in 1996 by the World Health Organization (WHO).

Background: Catatonia is an underdiagnosed and undertreated neuropsychiatric syndrome characterized by catalepsy, negativism, mutism, muscular rigidity, and mannerism, often accompanied by autonomic instability and fever. Although there is growing interest in studying cognitive impairments before and after catatonia, little is known about the cognitive features of the syndrome., Methods: This systematic review was registered at PROSPERO (CRD42022299091). Using a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach, we searched PubMed, ScienceDirect, and PsycArticles using a combination of the terms "Catatonia" and "Cognitive impairment" and "Executive function" and "Frontal lobe" and "Parietal lobe." Studies included original research articles enrolling patients with catatonic syndrome according to specified criteria. Fourteen studies were deemed relevant for inclusion. The abstraction form included age, assessment during acute episode, associated diagnosis, assessment procedure, and cognitive domains. Outcome measures were extracted., Results: Executive functions and visuospatial abilities proved to be the most investigated domains. A great heterogeneity has been observed in the assessment tools used among the 14 evaluated studies. Findings showed that catatonic patients had worse performance than healthy and non-catatonic psychiatric patients in frontal and parietal cortical functions., Conclusion: Because of the small number of studies in such heterogeneous areas and significant methodological limitations, the results should be regarded with caution. Future research assessing cognitive impairments on catatonic patients is needed., Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=299091], identifier [CRD42022299091]., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Serrat, Iglesias-Gónzalez, Sanagustin, Etxandi, de Pablo and Cuevas-Esteban.)

Catatonia is an undertreated and underdiagnosed neuropsychiatric syndrome whose prognosis is benign if treated early, thus avoiding possible complications and compromising the health of patients. The latest epidemiological studies indicate a prevalence of catatonia of 9.2%, being frequent in medical pathologies (especially neurological ones), as well as in psychiatric pathologies. The use of validated scales is recommended for its diagnosis, to be able to measure the severity and response to treatment. Once catatonia has been identified, it is necessary to perform a protocolized diagnostic study of the underlying aetiology («Catatonia Workup»). Treatment of choice is benzodiazepines and electroconvulsive therapy. In recent years, new therapeutic alternatives such as non-invasive transcranial magnetic stimulation have emerged. In this review we propose several initiatives to promote the dissemination and knowledge of catatonia in the clinical setting., (Copyright © 2021 Elsevier España, S.L.U. All rights reserved.)

Background: Immune mechanisms are part of the pathophysiology of mental disorders, although their role remains controversial. In depressive disorders a chronic low-grade inflammatory process is observed, with higher interleukin-6 (IL-6) values. Furthermore, in SARS-CoV2 infection, which is closely related to depressive disorders, there is a proinflammatory cascade of cytokines that causes systemic inflammation., Methods: The present study evaluates the relationship between IL-6 and C-reactive protein (CRP) serum levels and the presence of depressive and adjustment disorders in a sample of 1851 patients admitted to hospital for SARS-CoV2 infection from March to November 2020. Concentrations of IL-6 and CRP were determined within the first 72 ​h at admission and compared among groups of patients according to previous history and current presence of depression or adjustment disorders., Results: IL-6 serum levels were significantly higher in the group of patients with depression and adjustment disorders compared to patients without such disorders (114.25 ​pg/mL (SD, 225.44) vs. 86.41 (SD, 202.97)), even after adjusting for several confounders. Similar results were obtained for CRP (103.94 ​mg/L (SD, 91.16) vs. 90.14 (SD, 85.73)). The absolute levels of IL-6 and CRP were higher than those of previous depression studies, and differences were only found for the subgroup of De Novo depressive or adjustment disorders., Conclusions: Serum concentrations of IL-6 and CRP are higher in COVID-19 patients with De Novo but not persistent depressive or adjustment disorders. Clinical features such as fatigue, asthenia, anhedonia, or anxiety can be the basis for this finding., Competing Interests: ☒ The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors.)

Objective: To ascertain the clinical characteristics of anti-NMDA receptor encephalitis (NMDARE) in older patients., Method: A systematic literature review using PubMed and Scopus of all published case reports of NMDARE was undertaken, from database inception to June 2020. From this, cases reporting on patients older than 65 years of age and whose diagnosis was confirmed by the presence of anti-NMDAR antibodies in CSF were selected., Results: 23 case reports fulfilling the study's criteria were found. Median age was 70.1 years (range 65-84), fourteen were female (60.9%), and mostly presented with acute behavioral and cognitive changes (95.7%). Atypical psychosis occurred in eleven patients (47.8%) with a sudden onset and fluctuating clinical pattern of delusions (39.1%), hallucinations (30.4%), and motility disturbances (34.8%) including catatonia (17.4%). Nine patients presented with seizures (39.1%). Pleocytosis in CSF (>5 WBC) was described in twelve cases (52.2%). Eleven cases (47.8%) had abnormal brain magnetic resonance imaging (MRI) scans with limbic inflammatory lesions. Thirteen patients had an abnormal EEG (56.5%)., Conclusion: NMDARE should be included in the differential diagnosis of older patients who present with new psychiatric episodes, especially when characterized by sudden onset psychotic polymorphic symptomatology, fluctuating course with marked cognitive decline, and with catatonic features., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To determine how mental disorders and psychopharmacological treatments before and during COVID-19 hospital admissions are related to mortality., Methods: Subjects included in the study were all adult patients with a diagnosis of COVID-19, confirmed clinically and by PCR, who were admitted to a tertiary university hospital in Badalona (Spain) between March 1 and November 17, 2020. Data were extracted anonymously from computerized clinical records., Results: 2,150 subjects were included, 57% males, mean age 61 years. History of mental disorders was registered in 957 (45%). Throughout admission, de novo diagnosis of mood or anxiety, stress, or adjustment disorder was made in 12% of patients without previous history. Delirium was diagnosed in 10% of cases. 1011 patients (47%) received a psychotropic prescription during admission (36% benzodiazepines, 22% antidepressants, and 21% antipsychotics). Mortality rate was 17%. Delirium during admission and history of mood disorder were independently associated with higher mortality risk (hazard ratios, 1.39 and 1.52 respectively), while previous year's treatments with anxiolytics/hypnotics and antidepressants were independently associated with lower mortality risk (hazard ratios, 0.47 and 0.43, respectively)., Conclusion: Mental symptoms are very common in patients hospitalized for COVID-19 infection. Detecting, diagnosing, and treating them is key to determining the prognosis of the disease and functional recovery., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Background: Suicide is one of the leading causes of premature death in first-episode psychosis (FEP) patients. The understanding of suicidal behaviour (SB) is limited, and new and integrative approaches focusing on the likely relationship of the biological and cognitive features of SB in the early phases of psychosis are warranted. We aimed to study the relationship of brain grey matter anomalies and cognitive functioning with SB or suicidal risk in a large sample of non-affective FEP patients., Methods: We used a voxel-based morphometry analysis in 145 FEP patients to investigate the pattern of structural brain abnormalities related to SB. In addition, bivariate and multivariate analyses were performed to explore the relationship between cognitive functioning and SB., Results: A reduction in grey matter volume in the frontal area, temporal gyrus, precuneus, uncus, amygdala, left cuneus and subcallosal gyrus as well as a marked regional volume reduction in the right hemisphere was linked with the presence of SB. Additionally, worse global cognitive functioning and living in urban areas were identified as suicide risk factors., Conclusions: This study provides some insights about the brain abnormalities associated with SB in FEP patients. Specifically, the areas reported are involved in important functions related to SB, such as impulsivity, problem solving or responses to pain. Thus, the results confirm the relevant role of cognitive functioning on SB., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest concerning the subject of the study., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Working memory (WM) refers to the capacity system for temporary storage and processing of information, which is known to depend on the integrity of the prefrontal cortex. Impairment in working memory is a core cognitive deficit among individuals with psychotic disorders. The Corsi block-tapping test is a widely-used instrument to assess visuospatial working memory. The traditional version is composed of 9 square blocks positioned on a physical board. In recent years, the number of digital instruments has increased significantly; several advantages might derive from the use of a digital version of the Corsi test., Methods: This study aimed to compare the digital and traditional versions of the Corsi test in 45 patients with psychotic disorders and 45 healthy controls. Both groups completed a neuropsychological assessment involving attention and working memory divided into the two conditions., Results: Results were consistent between the traditional and digital versions of the Corsi test. The digital version, as well as the traditional version, can discriminate between patients with psychosis and healthy controls. Overall, patients performed worse with respect to the healthy comparison group. The traditional Corsi test was positively related to intelligence and verbal working memory, probably due to a more significant effort to execute the test., Conclusions: The digital Corsi might be used to enhance clinical practice diagnosis and treatment.The digital version can be administered in a natural environment in real-time. Further, it is easy to administer while ensuring a standard procedure.

Introduction: Context processing deficiencies have been established in patients with schizophrenia and it has been proposed that these deficiencies are involved in the formation of positive symptoms., Method: We administered a temporal context discrimination task to 60 schizophrenia patients and 60 healthy individuals. Pictures were presented in two sessions separated by half an hour and the participants were required to remember afterwards whether the pictures had been presented in the first or the second session., Results: The number of temporal context errors was significantly increased in the patient group. More specifically, it was highly significantly increased in a subgroup of patients presenting hallucinations, while the patients without hallucinations were equivalent to the healthy individuals. Regression analyses revealed that, independently of memory of the pictures themselves, verbal and visual hallucinations, as well as thought disorganisation, were associated with more temporal context errors. In contrast, affective flattening and anhedonia were associated with fewer of these errors., Conclusion: Inability to process or remember the temporal context of production of events might be a mechanism underlying both hallucinations and thought disorganisation., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Hallucinations have been found to be associated with various types of source memory failure in both schizophrenia patients and hallucination-prone healthy individuals. We investigated the associations of clinical and non-clinical hallucinations with source memory errors in a visual memory task that involved the remembering of picture presentation context. 59 schizophrenia patients and 61 healthy individuals took part in the study. Pictures were presented either at different locations or in association with different visual stimuli. The participants were required afterwards to recognize the target pictures among distractors, and then to remember their spatial location or the visual stimulus that was associated with them. Liberal response bias in picture recognition was associated with hallucination proneness and auditory-verbal hallucinations in subsamples of participants with significant non-clinical or clinical hallucinations. After controlling for overall memory performance, failure to remember the spatial location of the pictures was associated with visual hallucinations in male patients; failure to remember the associated visual stimulus was related to auditory-verbal hallucinations in female patients and to hallucination proneness in healthy women. The findings suggest that both clinical and non-clinical hallucinations are associated with loss of contextual information relative to the acquisition of events., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Structural brain abnormalities, including decreased gray matter (GM) and white matter (WM) volume, have been observed in patients with schizophrenia. These decrements were found to be associated with positive and negative symptoms, but affective symptoms (depression and anxiety) were poorly explored. We hypothesized that abnormalities in GM and WM volume might also be related to affective symptoms. GM and WM volumes were calculated from high-resolution T1 structural images acquired from 24 patients with schizophrenia and 26 healthy controls, and the associations of positive, negative, and affective symptoms with the brain volumes that showed significant reduction in patients were investigated. Patients demonstrated GM volume reductions in the bilateral prefrontal cortex, and WM volume reductions in the right frontal and left corpus callosum. Prefrontal cortex volume was significantly and inversely associated with both auditory-verbal hallucinations and depression severity. WM volume alterations, in contrast, were related to alogia, anhedonia, and delusions. The combined impact of auditory-verbal hallucinations and depression on similar sub-regions of the prefrontal cortex suggests that depression is involved in hearing voices. Further, this adverse impact of depression on prefrontal GM volume may underlie the impairment demonstrated by these patients in cognitive tasks that rely on executive processes., (Copyright © 2018. Published by Elsevier B.V.)

Objectives: The current study aimed at evaluating the reliability, convergent and divergent validity, and factor structure of the Spanish Launay-Slade Hallucinations Scale-Extended version (LSHS-E) in people with mental disorders and healthy controls., Methods: Four hundred and twenty-two individuals completed the Spanish LSHS-E and the Spanish Community Assessment of Psychic Experiences. The convergent and divergent validity of the LSHS-E was assessed with the three dimensions of the Community Assessment of Psychic Experiences (positive, negative, and depressive dimensions) in healthy controls and people with a mental disorder. Factor structure of the LSHS-E was assessed using confirmatory factor analysis and measurement invariance., Results: The LSHS-E had a good reliability in healthy controls and people with a mental disorder (Cronbach's = 0.83 and 0.91, respectively). The LSHS-E was more strongly associated with positive psychotic-like experiences than with depressive and negative symptoms. Four factors were found: (a) "intrusive thoughts"; (b) "vivid daydreams"; (c) "multisensory hallucination-like experiences"; and (d) "auditory-visual hallucination-like experiences" that were invariant between the group of healthy controls and people with a mental disorder., Conclusion: The Spanish version of the LSHS-E possesses adequate psychometric properties, and the confirmatory factor analysis findings provide further support for the multidimensionality of proneness to hallucination in clinical and nonclinical samples., (© 2018 John Wiley & Sons, Ltd.)