Despite the importance and interest in the editorial process at medical journals, more information is needed about immediate editorial decision whether editorial rejection or acceptance. The editor in chief (EIC) is in charge of the whole editorial process and decisions including the desk rejection or acceptance based on desk review. The early reject process is somewhat controversial and needs to be transparent and fair. There are many publication on editorial rejection, however little is known about editorial acceptance. This editorial answers many questions raised by researchers Vs. What is a desk reject/acceptance? Why are manuscript desk rejected? How often and when does this happen? What can authors do if manuscript is desk rejected?