Issue 4 of the Acute Medicine Journal (AMJ) reports an interesting exchange between the authors of a service evaluation investigating the prevalence of subarachnoid haemorrhage (SAH) in patients undergoing a lumbar puncture (LP)¹, and readership colleagues evaluating its merit, in light of the current evidence base and clinical recommendations². This discourse highlights the two phases of scientific peer review, which operates as the quality control mechanism for academic publishing.

Voase and colleagues authored a service evaluation analyzing 677 cases of patients undergoing LP over four years in the acute medical and emergency medicine setting, to assess the prevalence of SAH. The authors found a very low diagnostic yield with only one patient (0.1%) diagnosed with aneurysmal SAH requiring intervention, suggesting that LP may not be routinely necessary following a negative CT head scan in patients with acute severe headache. The authors argued instead for careful evaluation of the indication and clinical need for LP in patients with acute severe headache and a normal CT head scan, and suggested that many LP could be safely deferred to a semi-elective next-day setting to optimize resource use and patient care, while still acknowledging the limitations of their service review¹.

Gyan and colleagues wrote to the Editorial team highlighting the risks of selection bias in the published manuscript, the publication of newer NICE guidance since the study period, and the importance of CT timing relative to headache onset. The authors also emphasize LP’s broader diagnostic utility beyond detection of aneurysmal SAH, including infections and other intracranial conditions, and stress the need for careful clinical assessment and caution before adopting alternative diagnostic pathways, such as CT angiography².

Voase and colleagues have availed the opportunity to respond to the critique regarding their service evaluation, acknowledging study limitations and emphasizing that while LP is valuable, its routine use in low-risk, CT-negative patients delivers a low diagnostic yield. Voase and coauthors conclude by reiterating their findings, advocating for tailored diagnostic pathways balancing risks and benefits, and suggesting the need for further prospective clinical evaluations, and coordinated clinical protocols agreed upon between acute medicine, neurology and neurosurgery specialists³.

The exercise of peer review is comprised of the pre-publication and the post-publication phases, as it acts as a multi-stage process, aiming to assess research methodology, ensure originality, and uphold academic integrity.

At the start of phase 1, any manuscript submitted to the AMJ undergoes an initial step of “submission and desk review”, in which the Editor-in-Chief (EiC) and other journal staff evaluate the paper to see if it fits the journal’s scope, meets formatting guidelines, and holds sufficient academic merit. At this very initial point the paper can be desk rejected, without external review, or alternatively progress to the next step (refereeing), involving external peer reviewers.

The manuscript progressing to the subsequent step, the external refereeing process, undergoes further assessment by independent experts (usually 2 to 6 peers) in the specific research field. AMJ operates a double-blind model, where neither authors nor reviewers know each other’s identities.
Following the first two steps described above, the manuscript’s assessment can lead to acceptance, minor or major revisions, or rejection. The EiC makes the final decision at this stage.
Phase 2 is the post-publication (validation and discourse) stage, in which the published paper is evaluated by the broader scientific community, reading and evaluating the findings. This occurs through letters to the editor, academic debates and conferences, specialized post-publication platforms, and ongoing citations. The resulting continuous scrutiny helps detect errors, biases, and verify reproducibility of the findings. At this stage authors and readers can suggest further corrections, request retractions, or submit expressions of concern, etc.
As the AMJ completes its first year under new Editorial leadership, we have witnessed robust scientific discourse confirming an active and interested readership and a thorough selection process. We therefore wish to take this opportunity to thank our dedicated peer-reviewers, the AMJ’s editorial team and our readership for their involvement and commitment to the very important process of post-publication peer review.

References

1. Voase S, Stroud R, Upcott M, et al. To LP or not to LP? A service evaluation investigating the prevalence of subarachnoid haemorrhage in patients undergoing a lumbar puncture in the acute medical setting. Acute Medicine 2025; 24: 68–74.
2. Gyan C, Monaghan M, Sreenivasan S. Letter to Editor: Lumbar puncture in patients with acute severe headache. Acute Medicine 2025; 24: 175–176.
3. Voase S, Underwood J. Response to Letter to Editor. Acute Medicine 2025; 24: 177–178.