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The parametric variables of the demographic data, including age and treatment period were evaluated using two-tailed unpaired Student's t test with Welch's correction. Data are represented as mean SD. Chi-square test was applied to the non-parametric variables, including sex and underlying medical disease. The regression of chest radiography was.

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Of bone loss in COPD is complex but probably includes smoking, vitamin D deficiency, low BMI, hypogonadism, sedentary lifestyle, and use of corticosteroids [Biskobing, 2002]. Other systemic manifestations of COPD Patients with COPD are at increased risk of depression [Coultas et al. 2007], cognitive dysfunction, especially in those with hypoxemia [Antonelli-Incalzi et al. 2003] and chronic anemia [Cote et al. 2007] All of these factors are associated with poor outcomes in COPD. The impact of systemic consequences of COPD on mortality In the past, COPD mortality research has focused on measurements of lung function, especially FEV1 . Although FEV1 correlates with survival in COPD, the relationship is rather weak probably because FEV1 does not fully capture the extra-pulmonary manifestations of COPD that have been discussed in the previous sections. Prognostic indices that incorporate systemic elements of COPD perform much better than does FEV1 alone. A recent example is the BODE index. The BMI, airflow obstruction, dyspnea, and exercise capacity BODE ; index is a multidimensional instrument that is derived from BMI, FEV1 , modified Medical Research Council dyspnea score and 6-minute walk distance [Celli et al. 2004]. The BODE index is, therefore, an integrated scale that captures respiratory function, cardiovascular fitness, nutritional status, and skeletal muscle performance of COPD patients. A one-point increase in the BODE index is associated with a 34% increase in all-cause mortality RR, 1.34; 95% CI, 1.26 to 1.42 ; . Overall, the BODE index is much better than FEV1 alone in predicting risk of all-cause and respiratory-cause specific mortality. Conclusion COPD can be described as a chronic inflammatory disease of the lungs, the progression of which is often characterized by the development of extra-pulmonary diseases. These systemic manifestations such as cardiovascular diseases, skeletal muscle dysfunction and osteoporosis, contribute a great deal to reduced quality of life and increased mortality in COPD patients. Although the mechanisms for the association of COPD with these systemic disorders have not been fully worked out, local and systemic inflammation, oxidative stress, and perturbations in the neurohumoral states are some of the likely candidate pathways by which these extra-pulmonary complications of COPD are effected. Future work will undoubtedly shed more light on the processes and mechanisms for the extra-pulmonary manifestations of COPD. In the meantime, when assessing COPD patients, physicians must be mindful of these extra-pulmonary manifestations of COPD including cardiovascular disease, osteoporosis, cachexia, muscle weakness, anxiety, and depression. In addition to a careful history and physical examination, appropriate investigations are needed to ascertain these co-morbidities in COPD patients. Once detected, these extra-pulmonary manifestations of COPD should be treated aggressively, as they add to the overall morbidity and mortality of COPD patients. In general, smoking cessation and pulmonary rehabilitation can be recommended to patients to modify some of these processes. Acknowledgments DDS is a Senior Scholar with the Michael Smith Foundation for Medical Research and a Canadian Research Chair in COPD. The work is supported in part by the Canadian Institutes of Health Research and the GlaxoSmithKline St. Paul's Hospital Foundation Professorship in COPD. Conflict of interest statement The authors declare that there is no conflict of interest. References, for instance, 3m aldara. Ahmed M, Goucke CR 2002 ; Management strategies for the treatment of neuropathic pain in elderly. Drugs Aging 19 12 ; : 92945 Allcock N, McGarry J, Elkan R 2002 ; Management of pain in older people within the nursing home: a preliminary study. Health Soc Care Community 10 6 ; : 46471 American Geriatric Society AGS ; 1998 ; Clinical practice guidelines: the management of chronic pain in older persons. J Geriatr Soc 53 Suppl3 ; : S824 Bernabei R, Gambassi G, Lapane K, Landi F, Gatsonis C, Dunlop R, Lipsitz L, Steel K, Mor V 1998 ; Management of pain in elderly patients with cancer. J Med Assoc 279 13 ; : 187782 Blomqvist K 2003 ; Older people in persistent pain: nursing and paramedical staff perceptions and pain management. Issues Innovations Nurs Pract 41 6 ; : 57584 Briggs E 2003 ; The nursing management of pain in older people. Nurs Stand 17 18 ; : 4753 British Medical Association and Royal Pharmaceutical Society of Great Britain 2003 ; British National Formulary. The Pharmaceutical Press, London. Nor did the drug work on a pair of female ostriches and alendronate.

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