Second, prior meta-analyses had been post hoc without an a priori hypothesis and really should therefore be looked at hypothesis-generating rather than definitive.24 Observational studies may be flawed due to residual confounding by indication or other unknown factors that are presumably balanced in a randomized scientific trial.25 Although increased systemic contact with tiotropium through Respimat was a proposed description of earlier findings, pharmacokinetic studies show similar drug exposure, of delivery system regardless.7,8 Our study has many strengths.An editor at one of the journals released by Sage Publications became suspicious, sparking a comprehensive and lengthy investigation, in July 2014 which resulted in the retraction of 60 articles. At the ultimate end of 2014, BioMed Central and other publishers alerted the international Committee on Publication Ethics to new forms of systematic attempts to control journals’ peer-review processes. According to a statement published on COPE’s site in January 2015, these efforts to hijack the scholarly review system were apparently orchestrated by firms that first helped authors compose or improve their scientific articles and then sold them favorable peer evaluations.4 BioMed Central conducted a comprehensive investigation of most their recently published articles and identified 43 that were published based on evaluations from fabricated reviewers.