Pontifical Xavierian University

This paper explores the impact of fiscal policies on growth, welfare, and public deficits in tertiary education financing using a two‐sector growth model. It evaluates trade‐offs between public and private funding, comparing scenarios with and without budget deficit constraints. The results suggest that shifting to a user fee system can promote growth, but growth and welfare cannot be maximized simultaneously. For Colombia, increasing government spending on education, such as expanding infrastructure or hiring more teachers, improves welfare, while subsidies for user fees are ineffective. The study provides insights into the efficiency of mixed funding systems for higher education.

BACKGROUND The management of severe symptomatic aortic stenosis has been revolutionized by transcatheter aortic valve replacement (TAVR), offering a minimally invasive alternative to surgical aortic valve replacement (SAVR). However, the comparative safety and efficacy of these interventions remain subjects of ongoing investigation. AIM To compare the clinical outcomes and safety of TAVR vs SAVR in patients with severe symptomatic aortic stenosis. METHODS A systematic review and meta-analysis were conducted according to PRISMA guidelines. Randomized controlled trials (RCTs) comparing TAVR and SAVR were identified from databases including PubMed, Scopus, and Web of Science up to May 31, 2024. Data were extracted on clinical outcomes, including mortality, procedural complications, and post-procedure adverse events. Risk ratios (RRs) with 95%CIs were calculated using a random-effects model. RESULTS A total of 10 RCTs were included. TAVR demonstrated a significantly lower risk of acute kidney injury (RR: 0.33; 95%CI: 0.25–0.44), major bleeding (RR: 0.37; 95%CI: 0.30–0.46), and new-onset atrial fibrillation (RR: 0.44; 95%CI: 0.34–0.57) compared to SAVR. However, TAVR was associated with higher risks of new permanent pacemaker implantation (RR: 3.49; 95%CI: 2.77–4.39), major vascular complications (RR: 2.47; 95%CI: 1.91–3.21), and paravalvular leaks (RR: 4.15; 95%CI: 3.14–5.48). Mortality at 30 days was comparable (RR: 0.95; 95%CI: 0.78–1.15), but long-term mortality was slightly higher with TAVR in some analyses (RR: 1.23; 95%CI: 1.01–1.49). Rates of stroke (RR: 0.97; 95%CI: 0.81–1.17) and myocardial infarction (RR: 0.91; 95%CI: 0.67–1.24) were similar between the groups. CONCLUSION TAVR offers a less invasive option with significant benefits in reducing acute kidney injury, major bleeding, and new-onset atrial fibrillation, making it particularly advantageous for high-risk surgical candidates. However, higher risks of permanent pacemaker implantation, vascular complications, and paravalvular leaks highlight the need for individualized patient selection and shared decision-making to optimize outcomes. Key Words: Aortic stenosis; Meta-analysis; Surgical aortic valve replacement; Transcatheter aortic valve replacement; Treatment decision-making Core Tip: This systematic review and meta-analysis provide a comprehensive comparison of transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement in managing severe symptomatic aortic stenosis. TAVR demonstrated significant benefits, including reduced risks of acute kidney injury, major bleeding, and new-onset atrial fibrillation, particularly favoring high-risk surgical candidates. However, higher rates of permanent pacemaker implantation, vascular complications, and paravalvular leaks were observed with TAVR. Mortality and stroke rates were similar between interventions, underscoring the importance of individualized patient selection and shared decision-making to balance risks and optimize clinical outcomes.

Thoracic discectomy is performed via anterior or posterior approaches through different techniques. An updated comparison incorporating recent research is needed to inform clinical decision-making and guide future studies. A comprehensive search identified relevant studies, and meta-analyses evaluated neurological outcomes, complications, reoperations, and surgical efficiency metrics, including estimated blood loss (EBL) and length of stay (LOS). We pooled 37 studies (34 retrospective, 1 trial and 2 prospective) amounting to 27,450 patients. No significant differences were observed between anterior and posterior approaches for neurological improvement (OR 1.47, 95% CI 0.8-2.72), neurological worsening (OR 0.57, 95% CI 0.07-4.4), transient deterioration (OR 1.6, 95% CI 0.16-15.51), reoperations (OR 1.95, 95% CI 0.54-7.09), surgical site infections (OR 0.24, 95% CI 0.03-2.02), CSF leakage (OR 1.54, 95% CI 0.24-9.99), or postoperative neuropathic pain (OR 0.67, 95% CI 0.10-4.35). Operative time was similar (SMD 5.42, 95% CI-0.46 to 11.29). Mean EBL was lower for anterior approaches (600.1 mL, 95% CI 246.99-953.23) compared to posterior approaches (1925.1 mL, 95% CI 837.32-3012.88). The posterior approach had fewer overall complications (OR 0.32, 95% CI 0.24-0.42) and shorter LOS (SMD 0.48, 95% CI 0.25-0.71). Subgroup analysis confirmed that open approaches in both groups resulted in fewer complications and higher rates of neurological improvement. The choice of anterior vs. posterior approach for thoracic discectomy depends on patient factors and surgeon preference. Anterior approaches may provide better neurological outcomes but with potentially higher complication rates. Further research is needed to identify the optimal approach for each patient.

Background Extrapulmonary tuberculosis (EPTB) poses a public health challenge, particularly among individuals with human immunodeficiency virus (HIV). However, many EPTB cases arise in those without HIV, leaving the underlying factors unclear. Objectives This study aims to characterize patients with pulmonary tuberculosis (PTB) and EPTB, exploring the differences in associated factors for each type in patients with and without HIV. Design An analytical observational study was conducted on a cohort of tuberculosis (TB) patients diagnosed between 2014 and 2021 in a referral hospital in Bogotá, Colombia. Methods Patients were categorized into PTB or EPTB based on the site of infection. Data on demographic and clinical variables were collected, comparing the two groups. A multivariate logistic regression model was created to identify factors associated with EPTB compared to PTB. Results The study encompassed 533 patients: 310 with PTB and 223 with EPTB, of which only 65 (14.7%) were HIV positive. PTB patients exhibited higher rates of active smoking, smoking cessation, diabetes mellitus (DM), and other pulmonary diseases. The logistic regression identified HIV infection as the only factor associated with EPTB (OR 2.36 (1.54–3.61), p < 0.001). Conversely, quitting smoking (OR 0.58 (0.35–0.96) p = 0.038), DM (OR 0.41 (0.21–0.82) p = 0.011), chronic obstructive pulmonary disease (COPD) (OR 0.18 (0.08–0.4) p < 0.001), other pulmonary diseases (OR 0.21 (0.61–0.77) p = 0.019), or those using immunosuppressants (OR 0.44 (0.20–0.96) p = 0.04) exhibited a negative association with EPTB compared to PTB. Specific models for pleural and lymph node TB revealed distinct associations, with HIV strongly linked to lymph node TB (OR 3.38, 95% CI 1.57–7.26, p = 0.002). Conclusion EPTB is primarily associated with HIV infection, while smoking, DM, COPD, other pulmonary diseases, and immunosuppressant use are associated with PTB. Variability in associated factors for specific EPTB forms underlines the need for tailored research into the predisposing factors for EPTB, particularly in HIV-negative patients.

Background Dementia research in Latin America (LA) has primarily focused on Alzheimer's Disease and Frontotemporal Dementia, while Lewy body dementia (LBD) has been largely forgotten. Objective We aimed to review the available evidence on LBD in LA, offering a comprehensive perspective for understanding the lack of reports and the unique challenges and characteristics of this region. Methods We carried out a scoping review in databases: PubMed, EMBASE, LILACS, and Web of Science. Original studies that included participants with LBD were analyzed. Results Of the 1388 studies identified, 70 met the inclusion criteria for this review. Among them, 63 were cross‐sectional studies, three were cohort studies, two followed a case–control methodology, and only two were non‐randomized clinical trials. These studies primarily examined clinical manifestations, risk factors, neuropsychiatric and non‐motor symptoms, as well as cognitive impairment and its assessment in LBD within LA. Regarding geographical distribution, 52 studies were conducted in Brazil, seven in Argentina, the rest in Peru, Mexico, Colombia, Cuba, and Chile. Conclusions LBD research in LA is underrepresented, with most studies being cross‐sectional, few utilizing a longitudinal design, and only two clinical trials, both of which lack rigorous methodology. Challenges include weak study designs, high heterogeneity, limited trials, and unclear differentiation within the LBD spectrum. Addressing these gaps requires increasing awareness, strengthening research capacity, securing funding, and fostering international collaboration.

Objective This study aims to describe the clinical and social determinants associated with delirium in elderly patients hospitalized in the geriatrics department of Hospital Universitario San Ignacio (HUSI), in Bogotá, Colombia, between June 2019 and June 2022. Methods We conducted a retrospective analytical study. Data were extracted from the hospital's electronic medical records. The primary outcome was delirium upon admission. Exposure variables included clinical (e.g., malnutrition, dementia, oropharyngeal dysphagia) and social factors (e.g., living alone, social networks). Associations between delirium and exposure variables were assessed using a multivariate logistic regression model. Results The studied cohort comprised 4601 patients, mean age of 83.93 years and 56.26% were women. The prevalence of delirium upon admission was 22.39%. Key factors associated with delirium included older age (OR 1.04, 95% CI 1.01–1.06), malnutrition (OR 2.42, 95% CI 1.93–2.79), dementia (OR 2.57, 95% CI 2.02–3.38), functional impairment (OR 2.50, 95% CI 1.74–3.59), and oropharyngeal dysphagia (OR 1.49, 95% CI 1.08–1.99). Social determinants such as female sex, limited social networks, living alone, and enrollment in the subsidized health regime were not significantly associated with delirium. Conclusion Delirium upon admission is highly prevalent among elderly inpatients and is associated with clinical factors, particularly malnutrition, dementia, and oropharyngeal dysphagia. Although no significant associations were found between social determinants of health (SDH) and delirium in this cohort, further research in diverse healthcare settings is needed to better understand the broader impact of SDH on delirium risk.

The extent and distribution of tropical peatlands, and their importance as a vulnerable carbon (C) store, remain poorly quantified. Although large peatland complexes in Peru, the Congo basin, and Southeast Asia have been mapped in detail, information on many other tropical areas is uncertain. In the Eastern Colombian lowlands, peatland area estimates range from 700 km² to nearly 60,000 km², leading to highly uncertain C stocks. Using new field data, high‐resolution Earth observation (EO), and a random forest approach, we mapped peatlands across Colombian territory East of the Andes below 400 m elevation. We estimated peatland extent using two approaches: a conservative method focused on medium‐to‐high peat probability areas and a more inclusive one accounting for large low‐probability areas. Multiplying these extents by below‐ground carbon density yields a conservative estimate of 0.95 (0.6–1.39 Pg C, 95% confidence interval) over 9,391 km² (7,369–11,549 km²) and up to 2.86 Pg C (1.76–4.22 Pg C) across 29,069 km² (22,429–36,238 km²). Among four potentially peat‐forming ecosystems identified, palm swamps and floodplain forests contributed most to the peat extent and C stock. We found that most peatland patches were relatively small, covering less than 100 ha. We compared our map to previously published global and pan‐tropical peat maps and found low spatial overlap among them, suggesting that peat maps uninformed by local field information may not precisely specify which landscape areas within a peatland‐rich region are actually peatlands. We further assessed the suitability of different EO and climate variables, highlighting the need for high‐resolution data to capture local heterogeneities in the landscape.

INTRODUCTION Global life expectancy has steadily increased in recent decades, resulting in a significant rise in the number of individuals aged 80 years and older. This trend is also evident in Latin America, where life expectancy is improving, though at varying rates across countries and regions. METHODS Partnering with the Neurosciences Group of Antioquia (GNA), we launched a Colombian study on resilience in families with autosomal dominant Alzheimer's disease and the oldest‐old population. Over the past 2 years, the project has expanded to include participants from Peru, Chile, and Costa Rica. RESULTS This research led to the first symposium on Brain Resilience and Healthy Longevity, held in Medellín, Colombia, in August 2024. DISCUSSION The article summarizes key discussions from the symposium, highlighting the most promising opportunities for brain resilience and prevention research in the region and offering recommendations for future research to promote healthy aging and dementia‐free communities. Highlights Uncovering the genetic and physiological drivers of cognitive resilience, neurodegeneration resistance, and healthy longevity is essential for maintaining brain function as we age. “Superagers” and cognitively resilient individuals from Latin American families with Alzheimer's disease offer valuable insights into brain protection mechanisms. Studying the interplay of socio‐environmental and genetic factors in the oldest‐old is key to understanding healthy longevity and improving dementia prevention. The inaugural Brain Resilience and Healthy Longevity Symposium highlights the need for global collaboration to uncover factors that drive cognitive resilience and healthy aging in Latin America, advancing dementia prevention.

The pericardium is not simply a two‐layered membrane surrounding the heart and great vessels. Pericardial effusion is the most common manifestation of various pathological conditions involving the pericardium. Therefore, we are tempted to think of the pericardium as a virtual space containing only fluid, but it can also contain solid and cystic lesions. We must recall that clinical symptoms are non‐specific and may mimic cardiac, pulmonary, or pleural diseases. Imaging findings are not specific for a particular pathology, but when combined with the clinical history, can provide sufficient information to make an accurate differential diagnosis. In this review, we will identify selected entities affecting the pericardium, from benign to malignant, with a brief description of their clinical characteristics.

Aims To determine the diagnostic accuracy of mean nocturnal basal impedance (MNBI), in patients with suspected Gastroesophageal Reflux Disease (GERD), by comparing it to the updated 2023 Lyon Consensus Diagnostic Criteria. Additionally, to identify the optimal MNBI cut-off point for accurate GERD diagnosis. Furthermore, diagnostic accuracy of other complementary tests such as total number of reflux episodes, number of acid reflux episodes, bolus exposure time and DeMeester score for GERD diagnosis were evaluated [1] [2] [3] [4] [5]. Methods A diagnostic test study was conducted based on a retrospective cohort of patients with suspected GERD who were evaluated at the Hospital Universitario San Ignacio in Bogotá, Colombia, between July 2018 and August 2023. These dates were chosen as they span the period between the publication of the first Lyon consensus and its subsequent update in 2023. Patients over 18 years of age with symptoms suggestive of GERD, undergoing impedance-pH monitoring, and not receiving proton pump inhibitor treatment in the 4 weeks prior to the procedure were included. Variables related to endoscopic characteristics were systematically gathered prior to the pH-metry test. MNBI was obtained according to 24 hours impedance-pH monitoring. The diagnosis was made using the updated 2023 Lyon criteria as the gold standard. Sensitivity, specificity and discriminatory ability were evaluated using AUC-ROC. The best cut-off point was determined using Liu's method for MNBI, number of reflux episodes, number of acid reflux episodes, DeMeester score and bolus exposure time. ROC curves were compared using DeLong's method. Results A total of 55 patients were included in the study. Of these, 26 had a positive and 29 a negative diagnosis of GERD. MNBI discriminative ability for GERD diagnosis was suboptimal (AUC-ROC=0.77; 95% CI 0.64–0.89). The cutoff point with the higher simultaneous sensitivity and specificity was 1590 Ohms (sensitivity=69.2%, specificity=72.4%). MNBI cutoff points of<1500 Ohms and>2500 Ohms showed a sensitivity of 61% and 72.4% and a specificity of 88% and 41.4%, respectively. AUC-ROC, sensitivity and specificity for best cut-off points of other complementary tests were as follows: Total number of reflux episodes (88 reflux episodes), 69%, 72%, 0,80; Acidic reflux episodes (87 reflux episodes), 77%, 83%, 0,85; DeMeester score (15,6 points), 92%, 93%, 0,90; Bolus exposure time (1,6%) 69%, 66%, 0,73. AUC-ROC comparison showed superiority of the DeMeester score over the MNBI (p=0.03). No significant differences in discriminatory ability were found when comparing MNBI with the other complementary tests (p<0.05). Conclusions MNBI, as well as other complementary tests, showed suboptimal operational characteristics for the diagnosis of GERD. It is suggested to interpret these tests in conjunction with other clinical, endoscopic and pH-metry findings for GERD diagnosis. The DeMeester score seems promising, but future evidence from prospective studies is needed to prove its utility.

Treating type 2 diabetes has shifted from a gluco-centric approach to broader cardio-renal-metabolic strategy, driven by the use of disease-modifying medications. Traditionally, diabetes management has relied on stepwise medication addition based on failures in glucose control. However, the benefits and risks of combining glucagon-like peptide-1 receptor agonists (GLP1-RAs) and sodium-glucose cotransporter 2 inhibitors (SGLT2is) remain inadequately understood. This study conducted a scoping review to examine the available clinical research on the benefits and risks of combining GLP1-RAs and SGLT2is. Additionally, the nominal group technique was used to gather insights from medical experts from different areas regarding the combined therapy’s daily clinical use, concerns, and limitations. The review followed the guidelines outlined in the Joanna Briggs Institute Reviewer’s Manual and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). The final report includes 50 studies. The most common designs are observational studies. The median (IQR) number of patients across studies was 355 (1295). Studies reporting metabolic outcomes were the most common. The follow-up time ranges from 1.5 to 60 months. Although limited, the available evidence seems to support the combined use of GLP1-RAs and SGLT2is. The experts agreed that the underlying mechanisms appear synergistic rather than antagonistic for most outcomes. Combining medical therapy is common in diabetes treatment and may occur naturally in everyday practice. Limited evidence suggests that combined SGLT2is/GLP1-RAs therapy can potentially improve most but not all outcomes. Quality evidence and better-defined outcomes are paramount to guide the selection of patients for combined therapy.

Background Brain diffuse gliomas are highly epileptic and infiltrative tumors. Glioma surgery consists in the resection of the tumor core and the maximum of the peritumoral zone, infiltrated by tumor cells, guided by the intraoperative assessment of brain functionality and connectivity. However, its electrophysiological characteristics are poorly characterized. Methods We studied the characteristics of Electrocorticographic (ECoG) signals, in the context of glioma surgery in awake condition on 29 patients, using EEG activity sampled on the tumor itself versus on its borders and in healthy areas. We assessed the features of frequency bands and aperiodic components (offset and slope) of ECoG power spectra during awake glioma surgery, according to cortical tumoral vs peritumoral and healthy status. Results We found that tumor contacts present a decrease in activity for all the frequency bands except for delta activity, which was increased. Second, the peritumoral cortex was characterized by an increase in relative beta activity and slopes between 20-40 Hz. Low cortical tumor cell infiltration was directly correlated with a reduction in the production of physiological brain rhythms. Finally, an automatic classifier based on neural networks allowed the classification of the electrodes based on their power spectrum characteristics. Conclusions This intraoperative study shows that ECoG during glioma surgery in awake condition may characterize the peritumoral cortices, key for pathophysiology and therapy, and deepens our knowledge of the effects of tumor cells infiltration on nervous tissue activity. Its assessment during the surgical procedure should better delineation of the cortical areas to be removed.

Several diseases have been linked to αB‐crystallin (CRYAB) mutation. However, this mutation is an uncommon cause that has been associated in recent years with the development of dilated cardiomyopathy. We report a case of dilated cardiomyopathy with restrictive physiology due to a CRYAB mutation.

Objective Characterize the most frequently used ICD-10 diagnoses and procedures in the population aged 13–24 receiving care at Javesalud Healthcare Service Provider (HSP) in Bogotá, Colombia. Methods A cross-sectional quantitative study was conducted. Through the statistical program R Studio, a database provided by the HSP was analyzed, considering variables such as type of identification document, sex, age, primary ICD-10 diagnosis code, and consultation date. Patients aged between 13 and 24 attended by this HSP between June 1, 2022, and June 30, 2023, for 11.802 consultations, were included in the study. Results The analysis show a difference in the number of consultations according to gender (female/male ratio of 2.1:1), with a higher number of consultations from the young adult population (aged 19–24 years), who accounted for 57.4 % of the consultations. The data obtained indicates that the most frequent procedures involve promotion and prevention activities related to sexual and reproductive health, representing approximately 15 % of the consultations. Furthermore, the prevalence of various diagnoses was distributed differently according to the sex and age of the patients. For females, the most frequent diagnoses were similar but in different proportions, unlike males, where the main reasons for consultation behavior differed for each age group. While in adolescents, there is a predominance of two subgroups: dermatological diagnoses and follow-up exams, in young adults, HIV infection counseling predominates. Conclusions Adolescents and young adults constitute a group with epidemiological characteristics of great complexity, marked by a multitude of variables and significant interpersonal diversity. Therefore, it is imperative to conduct detailed studies in this age group and, at the same time, implement strategies that contribute to the promotion of their development and future well-being.

Introduction Retroperitoneal liposarcomas are rare malignant tumors that often present asymptomatically until advanced stages. Giant liposarcomas exceeding 30 cm are particularly uncommon, and colonic infiltration causing gastrointestinal bleeding is extremely rare, with only a few cases documented in the literature. Case presentation A 78-year-old female presented with hematochezia, constipation, and diffuse abdominal pain. Imaging revealed a large left para-aortic retroperitoneal mass compressing the colon. Colonoscopy showed colonic mucosal atrophy without active bleeding. Surgical exploration via midline laparotomy identified a bilobulated 89 × 35 × 40 cm retroperitoneal mass, infiltrating the left colon and compromising adjacent structures. En bloc resection, including hemicolectomy and left salpingo-oophorectomy, was performed. Histopathology confirmed a dedifferentiated liposarcoma with well-differentiated areas and colonic invasion reaching the muscularis propria. Margins were positive (R1). The patient recovered well postoperatively and experienced a single episode of intestinal obstruction at 6 months, resolved medically. Discussion Retroperitoneal liposarcomas typically exhibit compressive behavior rather than invasion. However, dedifferentiation is associated with aggressive features, including local invasion and higher recurrence rates. Colonic infiltration by giant liposarcomas is exceedingly rare, with only three additional cases reported. Mechanisms of bleeding include mucosal ischemia, compression, or direct histological infiltration, as observed in this case. Conclusion The relationship between gastrointestinal bleeding and colonic infiltration in retroperitoneal liposarcomas may reflect the association between tumor dedifferentiation and invasive behavior. This underscores the importance of curative-intent surgical management as the primary therapeutic strategy, despite the challenge posed by the proximity to critical neurovascular structures.

ABSTRACT *Objectives: To determine if identifying the metaphyseal exit can enhance intra- and inter-observer agreement in utilizing the Kfuri and Schatzker anatomical classification and selecting the appropriate surgical approach for tibial plateau fractures. *Methods: Design: Cross-sectional observational study. Setting: Academic hospital with access to advanced imaging technologies. Patient Selection Criteria: Tibial plateau fracture cases from January 2019 to March 2021 with complete image sets (AP and lateral knee radiographs, CT scans). Exclusion criteria included periprosthetic, neglected, or pathological fractures. Outcome Measures and Comparisons: Primary outcome measures were intra- and inter-observer agreement in fracture classification and surgical approach selection, quantified using Cohen’s and Fleiss Kappa coefficients. *Results: The study analyzed 63 cases. Intra-observer agreement improved from moderate to ’very good,’ especially in the third evaluation phase when the metaphyseal exit was identified alongside 3D CT imaging. Inter-observer agreement was generally low but improved when comprehensive image sets were available. Notably, the most experienced evaluator demonstrated significantly higher agreement in both fracture classification and surgical approach selection. *Conclusions: The identification of metaphyseal exit points significantly enhances agreement in fracture classification and surgical approach selection, addressing limitations of traditional systems. While surgeon experience and imaging availability remain critical, incorporating the metaphyseal exit into the Kfuri and Schatzker classification offers a reproducible framework for guiding treatment decisions. Level of evidence: III Diagnostic Study.

There is limited real-world evidence that evaluates the impact of monotherapy vs. combination therapy as a maintenance treatment in comorbid post-traumatic stress disorder (PTSD) in bipolar disorder (BD). Our aim was to compare lithium vs. lithium plus quetiapine in maintenance treatment in a sample of comorbid BD with PTSD. An exploratory, comparative pilot study over a 28-week period in 34 comorbid BD with PTSD patients was performed to compare monotherapy (n = 18) vs. combination therapy (n = 16) during maintenance treatment. The primary outcome was the time to event of recurrence of any mood episode. The secondary outcomes were regarding change from the baseline to endpoint in the Montgomery-Asberg Depression Rating Scale (MADRS) and Young Mania Rating Scale (YMRS). A Cox regression, Kaplan-Meir survival, and mixed-effects model for repeated measures analyses were performed. Lithium plus quetiapine reduces the risk of recurrence of any mood episode. There are significant differences between baseline and endpoint for YMRS, MADRS, and CGI-BP scales in the sample. In this pilot, exploratory analysis, combination therapy during maintenance treatment for comorbid BD with PTSD may be effective in preventing recurrences of any type of mood episode.