<table><tr><th>From: </th><th></th></tr><tr><td>Sent:</td><td>Tuesday, August 14, 2012 1:22 AM</td></tr><tr><td>To:</td><td>jeevacation@gmail.com</td></tr><tr><td>Subject:</td><td>Re:</td></tr></table>

<=ont face="Calibri">It's hard to know if his encephalopathy is a =rimary symptom or the result of hypoglycemia. <=ont face="Calibri">Anyway — was thinking through weird causes of=hypoglycemia. Best way to think about it is:

1. Either his bod= doesn't know how to regulate basic metabolism (reactive hypoglycemia)

2. He has fasting=hypoglycemia

3. He's u=der-producing glucose

<=ont face="Calibri">There are only these three paths (above) to hypoglyce=ia. I've exclude the common stuff or the "not likely" stuff since I =m sure Mayo has already tried those things.

<=ont face="Calibri">If his hypoglycemia is postprandial (after meals), th=n there are some very real things to think of in the category of reactive hypoglycemia — some are straight forward mechanical and the others =re errors of metabolism:

- Postoperative =apid gastric emptying (alimentary hyperinsulinism)

- Galactosemia

- Leucine intole=ance

<=ont face="Calibri">His diet sounds varied to me. Beans and rice means pr=tein and carbohydrates are tolerated to some degree. If it is a primary structur=l issue (like a glucose transporter gene mutation in the brain GLU-1 or GLU-3) or simple sugar or carbohydrate intolerance, you'd think he would do r=ally well on a ketotic diet, like super Atkins. Has he tried that?<=font> <=ont face="Calibri">You gotta wonder too about what happens when he fasts= Is that when he gets hypoglycemic? Cancer seems unlikely since he's ha= this whole life. Antibodies or weird islet cells could be the case.

Carnitine is reall= interesting, and he can buy it over the counter and give it a try.

- Islet cell dis=rders (adenoma, nesidioblastosis, cancer) seem unlikely given chronicity

- Antibodies to =ndogenous insulin

- Carnitine defi=iciency

<=ont face="Calibri">Finally, he might be under-producing glucose. There a=e tons of tests for this and I bet Mayo has run most of them.

- Glycogen metab=lism (glycogen phosphorylase, glycogen synthetase)

- Hexose metabol=sm (glucose-6-phosphatase, fructose-1,6-biphosphatase)

- Glycolysis, Kr=bs cycle (phosphoenolpyruvate carboxykinase, pyruvate carboxylase, malate dehydrogenase)

<=ont face="Calibri">I guess to start we'd need to know:

<=ont face="Calibri">...When is he hypoglycemic?</=ont> <=ont face="Calibri">...Has he tried a protein / ketotic diet?<=o:p> <=ont face="Calibri">...Has he tried supplementation with carnitine?=o:p> <=ont face="Calibri">...Do any of these things look familiar to him?=o:p> <=ont face="Calibri">...Does he get googly eyes after eating? Or eve= while sleeping?

<=ont face="Calibri">Interesting case. Between you and I — I bet w= can figure it out.

From: Jeffrey Epstein <jeevacation@gmail.com>
To: 
Sent: Mon, Aug 13, 2012 4:13 pm

so Jeffrey west gets goofy sleepy confused dazed every single t=me he eats anything„ sugars worse than other = he has live on rice and beans„ they say he is also severyly =ypoglycemic. 20 and under. mayo couldn't figure it=out, he has been to sleep strudies, mri, blood up the kazoo no=answer. probarbly stimulating the vegus nerve.????=br clear="all">

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