It is acknowledged that health technology assessment (HTA) is an inherently value-based activity that makes use of normative reasoning alongside empirical evidence. But the language used to conceptualise and articulate HTA's normative aspects is demonstrably unnuanced, imprecise, and inconsistently employed, undermining transparency and preventing proper scrutiny of the rationales on which decisions are based. This paper – developed through a cross-disciplinary collaboration of 24 researchers with expertise in healthcare priority-setting – seeks to address this problem by offering a clear definition of key terms and distinguishing between the types of normative commitment invoked during HTA, thus providing a novel conceptual framework for the articulation of reasoning. Through application to a hypothetical case, it is illustrated how this framework can operate as a practical tool through which HTA practitioners and policymakers can enhance the transparency and coherence of their decision-making, while enabling others to hold them more easily to account. The framework is offered as a starting point for further discussion amongst those with a desire to enhance the legitimacy and fairness of HTA by facilitating practical public reasoning, in which decisions are made on behalf of the public, in public view, through a chain of reasoning that withstands ethical scrutiny.

Rats were fed a grape seed extract (GSE) containing (+)-catechin, (−)-epicatechin and dimers, trimers, tetramers and polymeric procyanidins. Liver, kidney, brain and gastrointestinal (GI) tract together with plasma, urine and faeces were collected over a 24 h period and their flavan-3-ol content was analysed by HPLC with tandem mass spectrometry and diode array detection. Small amounts of the GSE flavan-3-ols moved out of the stomach and into the duodenum/jejunum, and to a greater extent the ileum 1 h after ingestion, and into the caecum after 2 h with relatively small amounts being detected in the colon after 3 h. The GI tract contained the parent GSE flavan-3-ols and procyanidins with only trace amounts of metabolites and there were no indications that proanthocyanidins were depolymerised in the GI tract releasing monomeric flavan-3-ols. Plasma contained exclusively catechin glucuronides and methylated glucuronide metabolites which were also detected in the liver and kidneys. These metabolites were also present in urine together with sulphated metabolites and low amounts of the procyanidin dimers B1, B2, B3 and B4 as well as the trimer C2 and an unknown GSE trimer. The amounts of (+)-catechin and (−)-epicatechin metabolites excreted in urine relative to the quantity of the monomers ingested were 27 and 36 %, respectively, after 24 h. This is similar to the levels of urinary excretion reported to occur by other investigators after feeding (−)-epicatechin to rats and provides further, albeit indirect, evidence that the procyanidin oligomers in the GSE were not depolymerised to monomers to any extent after ingestion. No convincing analytical data were obtained for the presence of flavan-3-ol metabolites in the brain.

Objective: To discover whether (as predicted in the literature) loss of contact with caring agencies is related to age, substance dependence, a history of law-breaking, or a diagnosis of schizophrenia.

Method: A consecutive series of 71 homeless people with mental disorders was recruited over a period of 18 months. The subjects were new referrals to psychiatrists working in a primary health care clinic for the homeless. The subjects were then followed up for a further 18 months (maximum follow up time 36 months, minimum follow up time 18 months) to determine duration of contact with Oxford services for helping the homeless (survival time).

Results: Survival analyses indicated that early loss of contact with Oxford services for helping the homeless was strongly predicted by substance (mainly alcohol) dependence in the month before first attendance at the clinic (generalised Wilcoxon 15.8, p<0.001). Homeless people with mental disorders who are also alcohol dependent, were five times more likely to lose contact with caring agencies than homeless people with mental disorders who were not alcohol dependent (hazard ratio 5.05,95% confidence limits 14.9-3.0).

Conclusions: Amongst homeless people with mental disorder, there appears to be an association between substance (mainly alcohol) dependence and loss of contact with caring agencies. This may be because homeless people with a dual diagnosis of mental disorder and substance dependence, tend to be more mobile than those who are not substance dependent.

A 61 year old man presented to the psychiatric services with an eight month history of musical hallucinations, unresponsive to neuroleptic medication. Investigation revealed hypertension with brain infarcts in the left temporal and left parietal lobes. Following reassurance that his hallucinations were organic rather than psychiatric in origin, they faded in significance.