From: Sent: Tuesday, August 14, 2012 1:22 AM To: jeevacation@gmail.com Subject: Re: <=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=iency <=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: Jeffre E stein <.eevacation mail.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"> EFTA_R1_01422252 EFTA02393590 The information contained in this communication is confidential, may be attorney-client privileged, may constitute inside information, and is intended only for the use of the addressee. It is the property of Jeffrey Epstein Unauthorized use, disclosure or copying of this corn m un 'cation or any part thereof is strictly prohibited and may be unlawful. If you have received this communication in error, please notify us immediately by return e-mail or by e-mail to jeev=cation@gmail.com <mailtojeevacation@gmail.com> , and destroy this communication and all copies thereof, including all attachments. copyright -all rights reserved 2 EFTA_R1_0 1422253 EFTA02393591