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The current trend in healthcare is to develop a stronger community service, with the aim of improving and maintaining patients' health, thereby avoiding hospital admission, with potential cost savings. In 2005, the Department of Health overhauled the way the National Health Service manages patients with chronic conditions by recruiting 3000 community matrons to provide care closer to home. The advantages of avoiding hospital admissions are as follows: a reduction in the cost of healthcare, a reduction in the incidence of hospital-associated problems and the provision of care closer to home. This is a service that provides active management of the patient in his or her own home by a healthcare professional, when otherwise hospital admission would have been required. The supporting evidence for intermediate care is weak, and is limited to early discharge of patients from secondary care.

A number of risk factors for chronic obstructive pulmonary disease (COPD) have been identified. The single most important cause of COPD is cigarette smoking, but other risk factors include the effect of diet, early childhood diseases and genetic factors. Individual susceptibility to developing COPD in relation to cigarette smoking varies. Fletcher C. and colleagues showed that although chronic bronchitis and progressive airway obstruction were both related to cigarette smoke, some conditions were distinct with regard to prognosis. Cannabis is often mixed with tobacco, and cannabis smokers often inhale more deeply than cigarette smokers. A dietary deficiency of antioxidants has also been postulated to increase the risk of COPD. Pre-existing bronchial hyper-responsiveness is another risk factor. Although there are many reports of a genetic association with COPD, few of these findings have been replicated in different populations. COPD is common among low socio-economic groups, due to high levels of smoking and poor nutrition.

Forty-five patients with advanced non-small cell lung cancer (NSCLC), with progressive inoperable tumors were treated. Twenty-three patients were of "limited" stage. Six patients had received previous thoracic radiotherapy. Patients with central nervous system (CNS) metastases, Karnofsky scores of less than 30 or more than 70, and patients over 70 years of age were excluded from the study. Cyclophosphamide (2.5 g/m2) was infused intravenously over 3 hours with the same Mesna dose. At the midpoint of the infusion, 3.5 g/m2 infosfamide was delivered as a bolus. Additional Mesna was administered over the next 8 hours. A maximum of four courses were given at three weekly intervals. One-hundred-thirty-eight courses were administered and 53% of patients completed all four treatments. The response rate was 38%, with three (7%) complete responses. Seven additional patients (15%) with stable disease symptomatically improved by two steps or more on the Karnofsky scale at the end of treatment. Median survival for all 45 patients was 7 months, range less than 1 to 25 months. Sixteen courses were complicated by Grade 3 thrombocytopaenia and/or leukopenia (Grade 4 on six occasions, Grade 3 on seven occasions) on the blood count taken immediately before chemotherapy. Intravenous antibiotics were required on 14% of the total number of courses; and three patients died of probable treatment related causes. Two episodes of severe ifosfamide encephalopathy occurred but recovery was complete, and four episodes of frank hematuria also occurred. The Karnofsky score was more than 70 in 33% of patients one month after the end of chemotherapy compared with 0% before treatment. Unlike many chemotherapeutic regimens for NSCLC, double alkylating agent treatment with ifosfamide and cyclophosphamide improved the performance status without major toxicity in a selected patient population. The overall survival, however, remains short and further alkylating agent combinations need to be considered in the future.