Brief interventions for alcohol misuse among people living with HIV: a meta-analysis

Background: One-third of people living with HIV (PLHIV) have alcohol misuse or alcohol use disorders which negatively affect course and outcome of HIV.Objectives: The meta-analysis sought to evaluate the effectiveness of brief interventions (BI) on alcohol and HIV outcomes in PLHIV with alcohol misuse.Methods: We included clinical trials published between 1990 and September 2022 on adults with harmful/hazardous alcohol use; only randomized clinical trials (RCTs) were included in the meta-analysis. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Clinical Trials.Gov, and the World Health Organization's International Clinical Trials Registry Platform databases. Cochrane's risk-of-bias assessment was used.Results: Eighteen studies were included in the narrative synthesis, and a meta-analysis could be performed on 13 studies. Among the included RCTs, seven showed a low risk and two showed a high risk of bias; others showed some concerns. There was no evidence of publication bias. Compared to the control, BI significantly reduces the drinks per drinking day (N = 5, Hedge's g= -0.45, 95%CI = -0.58, -0.32) and the number of heavy drinking days (N = 4, Hedge'sg = -0.81, 95% CI= -0.94, -0.67) between 3-6 months post-intervention. BI also reduces the odds of mortality by 42% (N = 7, OR = 0.58, 95% CI = 0.34, 0.99) in 6-12 months. BI does not change the alcohol risk scores and transition to harmful alcohol use; it does not improve adherence to Anti-Retroviral Therapy and increase viral suppression.Conclusion: Policymakers must introduce and scale up integrated screening and brief intervention services within HIV clinics and primary care.

Acute and transient psychotic disorders: A review of Indian research

Background

Acute and transient psychotic disorder (ATPD) was recognized as separate from other psychotic disorders and described in the International Classification of Diseases (ICD) tenth revision for the first time. A lot of research on ATPD has been conducted in India over the last six decades, but a review focusing exclusively on Indian research on ATPD is not available.

Aim

This paper aims to review the literature on ATPD emerging from India.

Methodology

A combination of search terms "Acute and Transient Psychosis," "acute psychosis," "non-affective psychosis," "non-affective psychotic disorder," "reactive psychosis," "first-episode psychosis," and "India" were searched on various search engines like PUBMED, Medknow, Hinari, and Google Scholar. We also did a hand search for additional relevant articles, including published abstracts of the Indian Journal of Psychiatry from 2007 to 2023. Relevant papers were selected.

Results

The prevalence of ATPD varies across different study settings, and it tends to have an abrupt to acute onset, and is primarily associated with stress. Few studies have assessed the subtypes of ATPD, and symptom profile has been inconsistently reported. There is a lack of trials on the effectiveness or efficacy of antipsychotics in ATPD patients. In a large proportion of patients initially diagnosed with ATPD, the diagnosis remains stable, with recurrence varying from 10% to 46.6% based on the duration of follow-up.

Conclusion

There is a need for more multicentric studies, studies with larger sample sizes, and consistency in data about risk factors. There is a need to evaluate symptom profile, course, outcome, and treatment outcomes in patients with ATPD using validated instruments to improve our understanding. Further, there is a need for comparative studies to evaluate the risk factors for ATPD.

Does Prescription Length of Buprenorphine Influence Treatment Outcomes in Opioid Use Disorder? A Retrospective Cohort Study from North India

OBJECTIVE

Buprenorphine (BUP) effectively suppresses non-prescription opioid use and increases treatment retention in opioid use disorder (OUD). However, short prescription length may interfere with treatment retention and recovery. We wanted to examine whether the outcomes of BUP treatment differ in high (HPL up to 4 wk) and low-prescription (LPL 1-2 wk) length groups.

METHODS

We compared time to treatment discontinuation (TD), non-prescription opioid-positive urine screen, buprenorphine-negative urine screen, and self-reported non-prescription opioid use between two different cohorts of LPL (case record: June 2018 to August 2019; n = 105; observation endpoint: 31 October 2019) and HPL groups (case record: June 2020 to Aug 2021; n = 133; observation endpoint: 31 October 2021). We used Kaplan-Meier survival analysis and log-rank tests for between-group comparisons. We used Cox regression analysis to adjust for age, opioid potency, comorbidities, family income, and marital status.

RESULTS

Subjects' age and buprenorphine dose were significantly lower, and the percentage of high-potency opioid users was significantly higher in the LPL group. In the unadjusted survival analysis, the median time to BUP discontinuation in the HPL was longer than that of the LPL [LPL= 22.4 ± 4.3 wk; HPL = 33.1 ± 8.5 wk; χ2(1)= 5.7; p=.02]. The survival distributions of other outcomes did not differ between groups. When adjusted for covariates, neither the prescription length nor other covariates independently predicted any treatment outcome.

CONCLUSION

Higher prescription length might be associated with longer treatment retention. We provide preliminary evidence to support greater flexibility in BUP treatment, enhancing its scalability and attractiveness.

The clinical profile and outcome of patients receiving continuation electroconvulsive therapy (C-ECT): A retrospective study

Background

There is a lack of data on the use of continuation electroconvulsive therapy (C-ECT) from India.

Objectives

This study aimed to evaluate the clinical profile and outcome of patients receiving C-ECT.

Materials and Methods

The ECT register was used to identify patients receiving C-ECT (ECT after completion of an acute course, to maintain remission or prevent relapse) from 2011 to July 2022. Socio-demographic, clinical, and treatment outcome details were extracted from their treatment records.

Results

A total of 72 C-ECT courses were identified that were used in 60 patients. Out of all the patients receiving ECT, only 3.25% of patients receive C-ECT. The majority of the patients were male (60%). The mean age of the patients at the time of starting ECT was around 39 years. The most common diagnosis was schizophrenia (73.3%), followed by recurrent depressive disorder (21.6%). The most common indication was persistent psychotic symptoms poorly responding to multiple antipsychotic trials of 3.09 (SD: 1.39), including clozapine. These patients received a mean of 22.58 (SD: 8.05; range: 10 to 46) ECTs, with 10.0 (SD: 4.83) ECTs for the management of the acute phase of illness and 12.57 (SD: 6.20) ECTs as part of continuation treatment. The majority (61.1%) of the patients received four (once weekly) C-ECTs in the first month, followed by three more in the next month. However, 16 patients received weekly ECTs during the second month too, as symptoms worsened with the lowering of frequencies. Twelve patients received more than one C-ECT course. The majority of the patients maintained the improvement gained during the acute phase or showed further improvement with C-ECT along with ongoing pharmacotherapy as rated on appropriate scales. The Clinical Global Impressions-Severity (CGI-S) difference before and after C-ECTs was 2.94 (SD: 0.88).

Conclusions

C-ECT is considered in only in a small proportion of patients. However, when used, it is effective in maintaining the benefits gained during the acute course of ECT and preventing relapse.

Development of a protocol for videoconferencing-based exposure and response prevention treatment of obsessive-compulsive disorder during the COVID-19 pandemic

BACKGROUND

The existing literature indicates that psychotherapeutic treatment, especially exposure and response prevention (ERP) is efficacious in treating obsessive-compulsive disorder (OCD). The coronavirus disease 2019 pandemic adversely impacted many patients with OCD and disrupted their usual treatment. Moreover, the pandemic forced a global switch to telemental health (TMH) services to maintain the standards and continuity of care. Consequently, clinicians are increasingly using TMH-based psychotherapeutic treatments to treat OCD. However, several challenges have made it difficult for them to implement these treatments in the changed circumstances imposed by the pandemic.

AIM

To describe the formulation, implementation, feasibility, and usefulness of videoconferencing-based ERP (VC-ERP) treatment for OCD during the coronavirus disease 2019 pandemic.

METHODS

This prospective, observational study was conducted in the psychiatric unit of a multi-specialty hospital in north India over 12 mo (July 2020-June 2021). All patients with OCD were assessed using the home-based TMH services of the department. The VC-ERP protocol for OCD was the outcome of weekly Zoom meetings with a group of clinicians involved in administering the treatment. After a systematic evaluation of the available treatment options, an initial protocol for delivering VC-ERP was developed. Guidelines for clinicians and educational materials for patients and their families were prepared. The protocol was implemented among patients with OCD attending the TMH services, and their progress was monitored. The weekly meetings were used to upgrade the protocol to meet the needs of all stakeholders. Feasibility and efficacy outcomes were examined.

RESULTS

All patients were diagnosed with OCD as a primary or a comorbid condition according to the International Classification of Diseases, 10^th version criteria. Out of 115 patients who attended the services during the study period, 37 were excluded from the final analysis. Of the remaining 78 patients, VC-ERP was initiated in 43 patients. Six patients dropped out, and three were hospitalized for inpatient ERP. Eleven patients have completed the full VC-ERP treatment. One patient completed the psychoeducation part of the protocol. VC-ERP is ongoing in 22 patients. The protocol for VC-ERP treatment was developed and upgraded online. A large proportion of the eligible patients (n = 34/43; 79%) actively engaged in the VC-ERP treatment. Drop-out rates were low (n = 6/43; 14%). Satisfaction with the treatment was adequate among patients, caregivers, and clinicians. Apart from hospitalization in 3 patients, there were no other adverse events. Hybrid care and stepped care approaches could be incorporated into the VC-ERP protocol. Therefore, the feasibility of VC-ERP treatment in terms of operational viability, service utilization, service engagement, need for additional in-person services, frequency of adverse events, and user satisfaction was adequate. The VC-ERP treatment was found to be efficacious in the 11 patients who had completed the full treatment. Significant reductions in symptoms and maintenance of treatment gains on follow-up were observed.

CONCLUSION

This study provided preliminary evidence for the feasibility and usefulness of VC-ERP in the treatment of OCD. The results suggest that VC-ERP can be a useful option in resource-constrained settings.

Clozapine research from India: A systematic review

BACKGROUND

Although clozapine is much researched in western literature, a review on Indian research on clozapine published in 2010 reported limited data and need for further research in this area.

AIM

We aimed to conduct a systematic review of research on clozapine from India from 2010 to mid-2022 and also compare the same with research output before 2010.

METHODOLOGY

A systematic various search engines, i.e., PUBMED, Medknow, Hinari and Google Scholar was done using the key words clozapine and India. Published articles with clozapine in the title and having an author from India, published during 2010 to July 2022 were included.

RESULTS

Initial Internet and hand searches yielded 280 articles, out of which 126 articles were excluded due to various reasons and 154 articles, were included for the review. This included 84 case reports, 49 original articles, 11 review articles and 10 letters to the editor as comments. We found an increase in the number of publications during the period of 2010-2022 compared to 1997-2009 in all types of publications. Over the years a significant proportion of the articles focused on various side effects of clozapine, factors associated with response and non-response to clozapine and evaluation of outcomes other than efficacy/effectiveness. However, all the studies were limited to a single centre with no multicentric studies on clozapine.

CONCLUSION

Over the last 12 years or so, there is increase in the number of publications on clozapine. However, there is lack of multicentric studies.

A Scoping Review of the Prevalence and Correlates of Sexual Dysfunction in Adults With Substance use Disorders

BACKGROUND

Substance use may affect sexual functioning in both men and women. Comorbid sexual dysfunction adds to the clinical burden of substance use disorders (SUD).

AIMS

The broad aims were to identify research conduct, types of the available evidence, and research gaps in (i) estimating the incidence, prevalence, type, and severity of sexual dysfunction in adults with SUD; (ii) exploring correlates of sexual dysfunction in SUD.

METHODS

We conducted systematic searches on PubMed, Google Scholar, and Embase for studies published in the English language between August 1954 and November 2020. We included prospective and cross-sectional observational studies that had examined the prevalence or incidence of any sexual dysfunction in adults of either gender with substance use disorders. Review articles and those with an exclusive focus on tobacco use disorders were excluded. The review was registered in PROSPERO.

RESULTS

Our search identified 65 relevant articles, including five prospective studies. All the prospective studies and most of the cross-sectional studies (n = 40) were done among men and subjects with alcohol (n = 20) and opioid (n = 23) use disorders in clinical populations. Substance use and sexual dysfunction were assessed by a wide range of instruments. Prospective studies reported a prevalence of sexual dysfunction at 75% and 61% for alcohol and opioid use disorders, respectively. The prevalence of any sexual dysfunction in cross-sectional studies ranged between 15 and 100 percent. Erectile dysfunction was the most commonly studied and observed sexual dysfunction. Comorbidity and socioeconomic deprivation were consistently associated with a higher occurrence of sexual dysfunctions.

STRENGTHS

We did not limit our review by the type of substances and year of publication. We adhered to the standards of conducting and reporting scoping reviews; hence, our review results should be replicable, transparent, and reliable.

LIMITATIONS

The wide clinical and methodological heterogeneity precluded a systematic review.

CONCLUSION

Research gaps exist in women, non-clinical population, stimulants, and cannabis use disorders, and effect of treatment of SUD in sexual functioning. The quality of evidence is poor. Ghosh A, Kathiravan S, Sharma K, Mattoo SK. A Scoping Review of the Prevalence and Correlates of Sexual Dysfunction in Adults With Substance use Disorders. J Sex Med 2022;19:216-233.

Physicians' Reactions to COVID-19: The Results of a Preliminary International Internet Survey

OBJECTIVES

Physicians across the world have been disproportionately affected by the COVID-19 pandemic. This study was designed and conducted to assess the emotional and behavioural reactions of physicians to the initial phase of the COVID-19 pandemic.

SUBJECTS AND METHODS

An online survey questionnaire using the google forms platform was constructed by the authors. The items in the questionnaire were based on clinical experience, relevant literature review and discussion with peers. A list of issues that were deemed as essential components of the experience of the pandemic relevant to physicians was arrived at. Thereafter these issues were operationalized into question form and hosted on the google forms platform. The link to this questionnaire was circulated by the authors among their peer groups in the month of April 2020.

RESULTS

We received 295 responses and 3 were unusable. Most of the responses were from India, the United States of America, Australia, Canada and the United Kingdom. About 60% of the respondents identified themselves as frontline and had a decade of clinical experience. Most respondents reported being anxious due to the pandemic and also observed the same in their peers and families. A majority also observed changes in behaviour in self and others and advanced a variety of reasons and concerns. A sense of duty was the most commonly employed coping mechanism.

CONCLUSION

Physicians are not immune from information and misinformation, or cues in the environment. Behavioural choices are not always predicted by knowledge but by a combination of knowledge, emotional state, personality and environment. Healthcare settings need to be ready for emergencies and should focus on reducing uncertainty in physicians. These factors may also be gainfully used in the mental health promotion of physicians in COVID-19 care roles.

The Experience and Reactions towards Stage 1 COVID-19 among Junior Doctors in India

BACKGROUND

COVID-19 pandemic is the first modern pandemic and has occurred in an era of social media ubiquity. Despite being in stage 1 of the pandemic, and low numbers of patients, various emotional and behavioral changes were observed in junior doctors. This study was designed to assess the experience and reactions of junior doctors in a tertiary teaching hospital in North India and Tamil Nadu in the immediate aftermath of the nation-wide lockdown.

SUBJECTS AND METHODS

This was an observational cross- sectional study of junior doctors working in tertiary care hospitals in Chandigarh and Tamil Nadu. It was conducted from 28^th March to 5^th April 2020. Ethical clearance obtained and anonymity was maintained. We used a 17-item self-designed questionnaire circulated online.

RESULTS

Mean age was 28.64 years (n=362). Though mostly well informed, only 8% restricted themselves to obtaining information from a single source. Around 46% were feeling anxious and many more (73.20%) perceived the same emotion in their peers and even more of them (85.10%) in their family members. Most of them (90.1%) endorsed more than change in behavior, mainly to avoid potential risk (52%) and females tend to self-quarantine themselves more than males.

CONCLUSIONS

Knowledge does not play as important a role in the way people behave in an outbreak. Many other covert factors may possible be involved. Strategies leading to reduction in uncertainty, interventions for reassurance in the workplace and better role models would be of help in this outbreak.

Delirium Research in India: A Systematic Review

Delirium is the most common psychiatric diagnoses encountered in patients with various medical-surgical illnesses, in all the treatment set-ups, with relatively higher incidence and prevalence in the intensive care units. As delirium is encountered in multiple specialties, it is important to understand the research on this diagnosis. This study aims to assess the research output involving patients of delirium from India. A comprehensive search was undertaken using Medline (PubMed) and other databases. Search words included were “delirium,” “delirious,” “delirium tremens” AND “India.” No filters were used. Internet and hand searches yielded 305 articles. Out of these articles, 151 had the terms “delirium,” “delirious,” “delirium tremens” in the title and these were included for the review. Additionally, 14 articles were included for the review, although these did not have these terms in the title, but delirium was one of the major outcome parameters in these studies. Majority of the papers were original articles ( n = 81), and these were followed by, case reports ( n = 58), review articles ( n = 10), letter to the editor (not as case reports but as a communication; n = 13), editorials ( n = 2) and one clinical practice guideline. Most of the original papers have either focused on epidemiology (incidence, prevalence, outcome, etc.), symptom profile, with occasional studies focusing on effectiveness of various pharmacological interventions. There is a dearth of research in the field of delirium from India. There is a lack of studies on biomarkers, evaluation of nonpharmacological interventions, and evaluation of prevention strategies. It is the need of the hour to carry out more studies to further our understanding of delirium in the Indian context.

Proactive case finding for severe mental illness in a rural area in the Indian Punjab: findings and lessons

People with severe mental illnesses may experience barriers in accessing community mental health services. We used the key informant method to detect people with untreated severe mental illness in seven villages in the Indian state of Punjab. The key informant was a local community leader. We were able to contact 11 patients who were identified as suffering from severe mental illness by the key informants. On assessment, eight of them had intellectual disability and three had psychotic and affective illness. We discuss the barriers and opportunities for providing mental health services in the community.

A study of emotional states in candidates undergoing the diagnostic process for COVID-19

BACKGROUND

Waiting for results is often associated with a state of anxiety and restlessness. The current study is intended to study the emotional state of people waiting for their results after undergoing COVID-19 testing.

METHODS

A descriptive study was done among 140 participants enrolled by simple random technique over a period of 1 month in May 2020. The participants who gave sample for COVID-19 were assessed for their emotional state at two stages - after giving sample and during the waiting period before telling results to them. A self-designed questionnaire focusing on the demographics and emotional state was submitted by the participants distributed to them as Google Forms. Wilcoxon signed-rank test and McNemar test were used to compare the statistical change in emotions over a period of time.

RESULTS

Around 63.6% and 68.8% of the participants had neutral emotional state after giving sample and before announcement of results, respectively. The mean score of agreement with decision to test was 9 ± 1.6 and discomfort related to testing was 4.6 ± 2.6 on Likert scale of 1-10. A statistically significant difference (P = 0.01) was observed in mean response for "something can be done to help" after giving sample (1.6 ± 0.4) and before announcement of results (1.8 ± 0.3).

CONCLUSIONS

Patients undergoing testing for COVID-19 undergo psychological turmoil and use various coping methods. Patients endorsed various suggestions including quicker generation of results, environmental changes and counselling services to help them cope better. Incorporating these suggestions may improve the diagnostic process in patients with COVID-19.

Crystal structure of methyl (2Z)-3-(4-chloro-phen-yl)-2-[(3-methyl-1H-indol-1-yl)meth-yl]prop-2-enoate

In the title indole derivative, C20H18ClNO2, the chloro-phenyl ring is almost perpendicular to the indole moiety, making a dihedral angle of 87.6 (1)°. The mol-ecular packing is stabilized by C-H⋯π inter-actions, which form a C(9) chain motif along [10-1]. In addition, there are weak π-π inter-actions [centroid-centroid distance 3.851 (1) Å] between the chains, involving inversion-related chloro-phenyl rings.

Methyl (2Z)-2-[(2-formyl-3-methyl-1H-indol-1-yl)meth-yl]-3-(4-meth-oxy-phen-yl)prop-2-enoate

In the title indole derivative, C₂₂H₂₁NO₄, the dihedral angle between the benzene and pyrrole rings of indole moiety is 1.8 (1)°. The plane of the 4-meth­oxy­phenyl ring is oriented with a dihedral angle of 60.7 (1)° with respect to the plane of the indole moiety. The mol­ecular packing is stabilized by C—H⋯O hydrogen bonds which form a V-shaped chain arrangement along the bc plane of the unit cell. In addition to this, C—H⋯π and π–π inter­actions [centroid–centroid distances = 3.8102 (11) and 3.8803(12) Å], which run along the b-axis direction, stabilize the mol­ecular packing.

2-[(Ferrocen-1-yl)(hydroxy)methyl]prop-2-enenitrile

In the title ferrocene derivative, [Fe(C5H5)(C9H8NO)], the dihedral angle between the enenitrile group and the substituted cyclopentadienyl ring is 71.2 (1)°. The cyclopentadienyl rings of the ferrocene moiety are arranged in an eclipsed conformation. The hydroxy group, and the corresponding methine H atom, are disordered over two sets of sites with site-occupancy factors of 0.744 (4) and 0.256 (4). An intramolecular C—H...O close contact is observed. In the crystal, O—H...N hydrogen bonds form aC(6) chain along [100].

Methyl 9-(4-meth-oxy-phen-yl)-19-methyl-3,12-di-aza-penta-cyclo-[10.7.0.0(2,10).0(3,8).0(13,18)]nona-deca-1(19),13(18),14,16-tetra-ene-10-carboxyl-ate

The title ester, C₂₇H₃₀N₂O₃, crystallizes with two independent mol­ecules in the asymmetric unit whose geometrical features are similar. In each mol­ecule, the pyrrolidine ring adopts an envelope conformation, with the fused C atom shared with the piperidine ring as the flap, and the piperidine ring adopts a chair conformation. In the crystal, C—H⋯π inter­actions link the inversion-related molecules and form a dimeric arrangement in the unit cell.

Partial trisomy 10p12.33 and partial monosomy 13q32.1: case report and a literature review

We report on a preterm neonate with a deletion of the distal long arm of chromosome 13q32.1 and partial trisomy of the short arm of chromosome 10p12.33. The patient has intrauterine growth retardation, microphthalmia, macrocephaly, holoprosencephaly, patent ductus arteriosus, aortic isthmus hypoplasia, right renal agenesis, imperforate anus, ambiguous genitalia, pleural effusion and vertebral anomaly. Analysis using an oligonucleotide microarray (U-array Cyto6000 array platform (Human Genome build: hg 18) indicated that there was a partial trisomy of chromosome 10(19.5 Mb gain) involving 298 oligonucleotides from 10pter to 10p12.33, and a partial monosomy of chromosome 13(18.3 Mb deleted) involving 313 oligonucleotides from 13q32.1 to 13qter. This is the first report of a patient with partial trisomy 10p12.33 and partial monosomy 13q32.1.

19-Ferrocenyl-18-oxa-8,16-diaza-penta-cyclo-[8.6.3.0.0.0]nona-deca-2(7),3,5-triene-9,17-dione

In the title compound, [Fe(C(5)H(5))(C(21)H(19)N(2)O(3))], both pyrrol-idine rings of the pyrrolizine substructure show an envelope conformation. In the ferrocenyl moiety, the unsubstituted cyclo-penta-dienyl ring is disordered over two orientations with site occupancies of 0.64 (2) and 0.36 (2). In the pyrrolizine ring, one C atom is disordered over two positions, with site occupancies of 0.71 (1) and 0.29 (1). Intra-molecular C-H⋯O inter-actions occur. The crystal packing is established through weak inter-molecular C-H⋯O and N-H⋯O inter-actions.

Methyl 3-[(1H-benzimidazol-1-yl)methyl]-1-methyl-4-(4-methylphenyl)-2′-oxopyrrolidine-2-spiro-3′-1-benzimidazole-3-carboxylate

In the title compound, C₂₉H₂₈N₄O₃, the pyrrolidine ring adopts a twist conformation whereas the oxindole and benzimidazole residues are approximately planar with maximum deviations of 0.159 (1) and 0.011 (1) Å, respectively. The oxindole residue is almost perpendicular to the benzimidazole residue, making a dihedral angle of 89.2 (1)°. The methyl-substituted benzene ring is oriented at angles of 47.7 (1) and 71.0 (1)°, respectively, with respect to the oxindole and benzimidazole residues. An intra­molecular C—H⋯O hydrogen bond is observed. In the crystal, mol­ecules associate via N—H⋯N hydrogen bonds, forming R₂²(9) dimers.

Methyl 4-(4-chlorophenyl)-3,3a,4,4a,5,12c-hexahydro-2-thianaphtho[1′,2′:3,2]furo[5,4-b]pyrrolizine-4a-carboxylate

In the title compound, C₂₅H₂₂ClNO₃S, both the pyrrolidinyl and thia­zolyl rings adopt envelope conformations whereas the dihydro­pyran ring adopts a half-chair conformation. The chloro­phenyl and naphthalenyl ring systems are oriented at a dihedral angle of 59.7 (1)°. The crystal packing is stabilized by an intra­molecular C—H⋯N hydrogen bond and weak inter­molecular C—H⋯π inter­actions.

Methyl 4-phenyl-1,2,3,3a,4,4a,5,12c-octa-hydronaphtho[1',2':3,2]furo[5,4-b]pyrrolizine-4a-carboxyl-ate

In the title compound, C₂₆H₂₅NO₃, both pyrrolidine rings adopt envelope conformations, whereas the dihydro­pyran ring adopts a half-chair conformation. The phenyl ring is oriented at an angle of 27.9 (1)° with respect to the naphthalene ring system. An intra­molecular C—H⋯O hydrogen bond is observed. The crystal packing is stabilized by weak inter­molecular C—H⋯π inter­actions.

Methyl 3-(4-methoxy-phen-yl)-1-methyl-1,2,3,3a,4,11b-hexa-hydro-benzo[f]chromeno[4,3-b]pyrrole-3a-carboxyl-ate

In the title compound, C(25)H(25)NO(4), the pyrrolidine ring exhibits an envelope conformation and the tetra-hydro-pyran ring exhibits a half-chair conformation. The crystal structure is stabilized by inter-molecular C-H⋯π inter-actions.

Methyl 3-(4-chlorophenyl)-1-methyl-1,2,3,3a,4,11c-hexahydrobenzo[f]chromeno[4,3-b]pyrrole-3a-carboxylate

In the title compound, C₂₄H₂₂ClNO₃, the dihedral angle between the naphthalene ring system and the chloro­phenyl ring is 67.44 (4)°. The pyrrolidine and dihydro­pyran rings exhibit envelope and half chair conformations, respectively. In the crystal structure, weak C—H⋯π inter­actions are observed.

Methyl 4-(4-chloro-phen-yl)-1,2,3,3a,4,4a,5,12c-octa-hydro-benzo[f]chromeno[3,4-b]pyrrolizine-4a-carboxyl-ate

There are two mol­ecules in the asymmetric unit of the title compound, C₂₆H₂₄ClNO₃. The dihedral angles between the naphthalene ring system and the chloro­phenyl substituent are 58.76 (9) and 51.59 (8)° in the two mol­ecules. In the pyrrolizine ring system, both the pyrrolidine rings adopt envelope conformations and the dihydro­pyran rings adopt half-chair conformations. In the pyrrolizine ring system of one of the mol­ecules, one of the C atoms is disordered over two positions with site occupancies of 0.69 (2) and 0.31 (2). The crystal packing is stabilized by weak intra­molecular C—H⋯O inter­actions and the crystal packing is stabilized by weak C—H⋯π inter­actions.

Methyl 9-p-tolyl-8a,9,9a,10,11,12,13,14a-octahydro-8H-benzo[f]chromeno[3,4-b]indolizine-8a-carboxylate

In the title compound, C₂₈H₂₉NO₃, the fused pyrrolidine and piperidine rings of the octa­hydro­indolizine unit exhibit envelope and chair conformations, respectively. The dihedral angle between the naphthalene ring system and the benzene ring is 40.37 (5)°. The crystal packing is stabilized by weak inter­molecular C—H⋯O inter­actions.

4'-Ferrocenyl-1'-methylacenapthylene-1-spiro-2'-pyrrolidine-3'-spiro-2''-indane-2,1'',3''(1H)-trione

In the title compound, [Fe(C₅H₅)(C₂₉H₂₀NO₃)], the acenaphthyl­ene ring system makes a dihedral angle of 83.77 (3)° with the indane-1,3-dione ring system. The central pyrrolidine ring exhibits a twist conformation. In the crystal, mol­ecules are linked by a weak inter­molecular C—H⋯O inter­action into a chain along the b axis. Two weak intra­molecular C—H⋯O inter­actions are also present.

Methyl 9-(4-bromo-phen-yl)-8a,9,9a,10,11,12,13,14a-octa-hydro-8H-benzo[f]chromeno[3,4-b]indolizine-8a-car-box-ylate

In the title compound, C₂₇H₂₆BrNO₃, the mean plane of the naphthalene ring system makes a dihedral angle of 22.0 (1)° with the bromo-substituted benzene ring. The pyrrolidine and piperidine rings exhibit envelope and chair conformations, respectively. An inter­molecular C—H⋯Br inter­action is observed.

Methyl 5-phenyl-1,2,3,4,4a,5,5a,13c-octahydro-6H-benzo[f]chromeno[3,4-b]indolizine-5a-carboxylate

In the title compound, C₂₇H₂₇NO₃, the pyrrolidine ring exhibits a twist conformation and the piperidine ring exhibits a chair conformation. The pyrrolidine ring makes dihedral angles of 54.47 (5), 51.50 (5) and 73.37 (6)° with the napthalene ring system and the tetra­hydro­pyran and phenyl rings, respectively. The structure is stabilized by intra­molecular C—H⋯O and C—H⋯N inter­actions.

Methyl 3-(4-bromophenyl)-1-methyl-1,2,3,3a,4,9b-hexahydrobenzo[f]chromeno[4,3-b]pyrrole-3a-carboxylate

In the title compound, C₂₄H₂₂BrNO₃, the dihydro­pyran ring adopts a half-chair conformation, whereas the pyrrolidine ring is in an envelope conformation. The bromo­phenyl group is oriented at an angle of 66.44 (4)° with respect to the naphthalene ring system. In the crystal structure, mol­ecules are linked into centrosymmetric dimers by C—H⋯π inter­actions and the dimers are connected via C—H⋯Br hydrogen bonds. The crystal structure is further stabilized by π–π inter­actions [centroid–centroid distance = 3.453 (1) Å].

Methyl 4-(4-methoxy-phen-yl)-1,2,3,3a,4,4a,5,12c-octa-hydro-benzo[f]chromeno[3,4-b]pyrrolizine-4a-carboxyl-ate

In the title compound, C₂₇H₂₇NO₄, both the pyrrolidine rings in the pyrrolizine ring system adopt envelope conformations, whereas the dihydro­pyran ring adopts a half-chair conformation. The methoxy­phenyl group is oriented at an angle of 53.72 (4)° with respect to the naphthalene ring system. Intra­molecular C—H⋯O hydrogen bonds are observed. The crystal structure is stabilized by weak inter­molecular C—H⋯π inter­actions.

6-Phenyl-5a,6,6a,7,12,13a-hexahydro-5H-benzo[6,7]indolizino[3,2-a]pyrrolizine

In the title compound, C₂₃H₂₂N₂, the central pyrrolidine ring adopts an envelope conformation. The benzene ring of the hexa­hydro­pyrroloisoquinoline ring system makes dihedral angles of 83.43 (6) and 61.99 (10)°, respectively, with the phenyl and pyrrole rings. In the crystal structure, weak C—H⋯π inter­actions are observed.

Methyl 1-methyl-3-p-tolyl-1,2,3,3a,4,11c-hexa-hydro-benzo[f]chromeno[4,3-b]pyrrole-3a-carboxyl-ate

In the title compound, C(25)H(25)NO(3), the dihydro-pyran ring adopts a half-chair conformation, whereas the pyrrolidine ring is in a twist conformation. The tolyl group is oriented at an angle of 82.92 (7)° with respect to the napthalene ring system. In the crystal structure, mol-ecules are linked into centrosymmetric dimers by C-H⋯π inter-actions involving the benzene ring of the tolyl group.

Methyl 5-ferrocenyl-5a-hydr-oxy-1-methyl-10-oxo-2,3,3a,4,5a,10-hexa-hydro-1H-indeno[1,2:2',3']furo[3',4'-b]pyrrole-3a-carboxyl-ate

In the title compound, [Fe(C(5)H(5))(C(21)H(20)NO(5))], the pyrrolidine and cyclo-penta-none rings exhibit a twist conformation. The pyrrolidine ring is almost perpendicular to the cyclo-penta-none ring, making a dihedral angle of 81.91 (6)°. The mol-ecular conformation is stabilized by an intra-molecular O-H⋯N hydrogen bond and C-H⋯O inter-actions. The crystal structure is stabilized by inter-molecular C-H⋯O inter-actions.

Methyl 2-(2,2,4-trimethyl-6-tosylperhydro-1,3-dioxino[5,4-c]pyridin-5-yl)acetate

The title compound, C₂₀H₂₉NO₆S, crystallizes with two mol­ecules in the asymmetric unit, with similar conformations. The dioxane and pyridine rings adopt twist conformations in both mol­ecules. The packing is stabilized by inter­molecular C—H⋯O hydrogen bonds.

Methyl 3-[ferrocen-yl(hydr-oxy)meth-yl]-1-methyl-2'-oxospiro-[pyrrolidine-2,3'-indoline]-3-carboxyl-ate

In the title compound, [Fe(C(5)H(5))(C(20)H(21)N(2)O(4))], the pyrrolidine ring exhibits an envelope conformation with the spiro-C atom deviating from the plane of the remaining four atoms. The pyrrolidine ring is almost perpendicular to the indolinone ring [dihedral angle = 87.52 (7)°]. The structure is stabilized by an intra-molecular O-H⋯N hydrogen bond and by inter-molecular C-H⋯O and N-H⋯O inter-actions.

1-Vinyl-1H-indole-3-carbaldehyde

In the title compound, C₁₁H₉NO, the C and O atoms of the attached carbaldehyde group deviate by just 0.052 (2) and 0.076 (1) Å, respectively, from the mean plane of the indole ring system. In addition to van der Waals forces, the mol­ecular packing is stabilized by C—H⋯O hydrogen bonds, which form a C(7) chain motif, and π–π inter­actions (centroid–centroid distance 3.637 Å) between the pyrrole and benzene rings of the indole ring system.