PCR Zones: Setup, Workflow, and Contamination Control
By Dr. Zubair Khalid, DVM, MS, PhD ·

Key Takeaways
- PCR zones are physically segregated laboratory areas designed to prevent amplicon contamination by separating pre-amplification (reagent and sample preparation) from post-amplification (thermal cycling and analysis) stages.
- The core principle is a unidirectional workflow from "clean" Zone 1 (reagent preparation) to "moderately contaminated" Zone 2 (sample preparation) to "dirty" Zone 3 (amplification/analysis), with no backward movement of materials or personnel.
- Amplicon contamination, arising from the exponential amplification of target DNA (up to 10¹² copies), is the most common cause of false positives and necessitates dedicated equipment, filter tips, UV irradiation, and rigorous decontamination protocols.
- Zone 1 is exclusively for preparing master mixes without template DNA, Zone 2 handles sample addition, and Zone 3 contains the thermal cycler and analysis equipment, where amplicons are expected and managed.
- Monitoring zone integrity through wipe tests, negative controls (NTCs), and environmental sampling is crucial to ensure the effectiveness of contamination control strategies.
Introduction to PCR Zones
What Are PCR Zones?
PCR zones are physically separated laboratory areas designated for specific stages of the polymerase chain reaction workflow. The fundamental principle is simple: keep the materials that go into a PCR reaction separate from the products that come out of it. A standard setup divides the laboratory into three distinct zones—reagent preparation, sample preparation, and amplification/post-PCR analysis—each with its own dedicated equipment, supplies, and traffic patterns.
The rationale for this spatial segregation stems from the extraordinary sensitivity of PCR. A single copy of a template molecule can, in theory, be amplified to detectable levels within 30–40 cycles. The polymerase chain reaction itself is an exponential process: after n cycles, a single starting molecule yields approximately 2ⁿ copies. After 30 cycles, that is over one billion amplicons. These amplified products, if they escape their container, become contamination that can ruin every subsequent experiment performed in that space.
PCR zones are not merely a matter of laboratory organization; they are a contamination control strategy grounded in the physics of aerosol generation and the chemistry of nucleic acid stability. DNA is a remarkably stable molecule. It withstands autoclaving temperatures (121°C) for short periods, survives desiccation, and adheres tenaciously to plastic surfaces. Once amplicon DNA contaminates a pipette, a benchtop, or a tube rack, it can persist for months and generate false positives across dozens of experiments.
Why Are PCR Zones Necessary?
PCR is uniquely vulnerable to contamination for three reasons. First, the target sequence is often present in vanishingly small quantities. Clinical samples, forensic specimens, and environmental DNA extracts may contain only tens or hundreds of copies of the target. Second, the amplification step produces enormous quantities of the same sequence—typically 10¹¹ to 10¹² copies per 25–50 µL reaction. Third, the detection methods used after amplification (gel electrophoresis, fluorescent probes, sequencing) cannot distinguish between a product derived from your intended template and one derived from a stray contaminant.
Consider a typical diagnostic PCR for a bacterial pathogen. The assay may detect as few as 10 genome equivalents per reaction. If a previous reaction amplified the same target and generated 10¹² copies, then a 1 µL aerosol droplet containing even 0.001% of that material carries roughly 10⁷ copies—enough to produce a strong false positive in any subsequent reaction. This is not a theoretical concern; amplicon contamination is the single most common cause of spurious PCR results in teaching and research laboratories.
The solution is to create a one-way flow of materials. Reagents and samples move from "clean" areas to "dirty" areas, never in reverse. This unidirectional workflow, combined with physical separation, dedicated equipment, and rigorous decontamination protocols, reduces contamination risk by orders of magnitude.
The Three Main PCR Zones
Zone 1: Reagent Preparation
Zone 1 is the cleanest area in the PCR workflow. Its purpose is to prepare master mixes—the cocktails of water, buffer, dNTPs (deoxynucleotide triphosphates), primers, and DNA polymerase that will be aliquoted into individual reaction tubes. No template DNA of any kind should ever enter this zone.
The reagent preparation zone typically contains a dedicated PCR hood or laminar flow cabinet, a set of pipettes used exclusively for reagent handling, and a refrigerator or freezer for storing primers, dNTPs, and polymerases. The hood is equipped with a UV lamp for decontamination between uses. When the hood is not in active use, the UV light is switched on to irradiate the interior surface and destroy any nucleic acid contaminants that may have settled there.
The master mix prepared in Zone 1 contains all reaction components except the template. A typical 50 µL PCR master mix includes:
- 5 µL of 10× PCR buffer (containing 100 mM Tris-HCl pH 8.3, 500 mM KCl, 15 mM MgCl₂)
- 1 µL of 10 mM dNTP mix (2.5 mM each of dATP, dCTP, dGTP, dTTP)
- 1 µL of 10 µM forward primer
- 1 µL of 10 µM reverse primer
- 0.25 µL of Taq DNA polymerase (5 U/µL)
- 41.75 µL of nuclease-free water
The exact composition varies by polymerase and application, but the principle holds: everything except the template is combined in Zone 1, then distributed into reaction tubes. The tubes are capped and transported to Zone 2 for template addition.
Zone 2: Sample Preparation
Zone 2 is where template DNA is added to the reaction tubes. This area handles clinical specimens, bacterial cultures, tissue samples, or any other source of nucleic acid. It is considered "moderately contaminated"—the samples themselves may contain pathogens, and the nucleic acid extracts are the intended targets of amplification.
The sample preparation zone contains a biological safety cabinet or PCR hood, dedicated pipettes for sample handling, a microcentrifuge, and a vortex mixer. DNA extraction may be performed here or in a separate area, depending on the laboratory layout. If extraction occurs in Zone 2, the zone also contains the reagents and kits for nucleic acid purification.
The critical rule for Zone 2 is that no amplified product—no PCR amplicon—may ever enter. This means that tubes containing completed PCR reactions must not be opened in Zone 2, and pipettes used in Zone 2 must never be used in Zone 1.
When adding template to the master mix, the workflow is: thaw the template DNA, vortex briefly to mix, centrifuge to collect the liquid at the bottom of the tube, then pipette the appropriate volume (typically 1–5 µL) into the labeled reaction tube. The tube is capped immediately after template addition. This step-by-step approach minimizes the time that tubes are open and reduces the opportunity for cross-contamination between samples.
Zone 3: Amplification and Post-PCR Analysis
Zone 3 is the "dirty" area of the PCR workflow. It contains the thermal cycler, gel electrophoresis apparatus, and any equipment used to analyze amplified products. This zone is expected to contain high concentrations of amplicon DNA, and it is treated accordingly.
The thermal cycler itself is a potential source of contamination. The heated lid and the block surface can accumulate DNA from tube exteriors or from tubes that leak during cycling. Regular decontamination of the thermal cycler with 10% bleach solution or a commercial DNA decontaminant is essential.
Post-PCR analysis in Zone 3 includes agarose gel electrophoresis, restriction enzyme digestion of amplicons, and sequencing reactions. All of these procedures generate aerosols and liquid waste that contain amplified DNA. The zone should have dedicated waste containers for gels, buffer, and tips, and these must be autoclaved or treated with bleach before disposal.
The key principle is that once a reaction has been amplified, it must never return to Zone 1 or Zone 2. Even a closed tube that has been through thermal cycling carries amplicon DNA on its exterior surface. Opening such a tube in a clean area releases that DNA into the environment.
Setting Up a PCR Workflow
Unidirectional Flow
The operational rule for PCR zones is unidirectional flow: work proceeds from Zone 1 (clean) to Zone 2 (sample) to Zone 3 (dirty), and never in reverse. This principle applies to personnel movement, equipment movement, and waste disposal.
A typical PCR experiment follows this sequence:
- Enter Zone 1. Put on a fresh lab coat and gloves. Prepare the master mix in the PCR hood. Aliquot into reaction tubes and cap them.
- Transport the capped tubes to Zone 2. Add template DNA to each tube. Cap the tubes immediately after template addition.
- Transport the completed reactions to Zone 3. Place them in the thermal cycler and run the amplification program.
- Analyze the products in Zone 3. Do not return any opened tubes, gels, or buffers to Zones 1 or 2.
Personnel movement follows the same pattern. A researcher who has been working in Zone 3 should not walk directly into Zone 1 without changing gloves and lab coat. Ideally, the zones are arranged in a linear sequence so that the natural flow of a workday carries researchers from clean to dirty areas.
Equipment and Supplies per Zone
Each zone requires its own dedicated equipment. Sharing equipment between zones defeats the purpose of physical separation. The table below summarizes the typical equipment allocation.
| Equipment/Supply | Zone 1 (Reagent Prep) | Zone 2 (Sample Prep) | Zone 3 (Post-PCR) |
|---|---|---|---|
| Pipettes | Dedicated set | Dedicated set | Dedicated set |
| Pipette tips | Filter tips only | Filter tips recommended | Any tips |
| PCR hood | Yes, with UV lamp | Yes, with UV lamp | Not required |
| Microcentrifuge | For reagent mixing | For sample processing | For product cleanup |
| Vortex mixer | Yes | Yes | Yes |
| Thermal cycler | No | No | Yes |
| Gel electrophoresis | No | No | Yes |
| Refrigerator/freezer | Reagents only | Samples only | Products only |
| Lab coat | Dedicated, clean | Dedicated | Dedicated |
| Gloves | Changed on entry | Changed on entry | Changed on exit |
Filter tips deserve special mention. These tips contain a porous barrier that prevents aerosolized liquid from reaching the pipette barrel. They are essential in Zones 1 and 2 because they prevent both sample-to-sample cross-contamination and contamination of the pipette itself. In Zone 3, filter tips are less critical because the risk is not contaminating your samples—it is preventing amplicons from spreading to clean areas.
Contamination Sources and Prevention
Types of Contamination
PCR contamination falls into three broad categories: amplicon contamination, sample-to-sample cross-contamination, and exogenous DNA contamination.
Amplicon contamination is the most common and the most dangerous. It arises from previously amplified PCR products. A single opened tube in a clean area can release billions of copies of the target sequence. These amplicons settle on surfaces, become aerosolized by pipetting, and persist for weeks or months. Amplicon contamination produces false positives that appear in negative controls and blank reactions.
Sample-to-sample cross-contamination occurs when DNA from one sample is transferred to another. This typically happens through shared pipettes, reusable tips, or aerosols generated during pipetting. Cross-contamination produces incorrect results that may not be detected by controls, since the contaminating DNA is a legitimate template.
Exogenous DNA contamination comes from the environment or the researcher. Human skin cells shed continuously and contain genomic DNA. If the PCR targets a human gene, even a few skin cells can produce a signal. Bacterial or fungal DNA from the environment can also contaminate reagents, particularly if the PCR targets conserved sequences like 16S rRNA. Reagents themselves can be contaminated during manufacturing; this is why nuclease-free water and molecular biology grade reagents are essential.
Preventive Measures
The most effective preventive measures are physical separation, dedicated equipment, and strict protocol adherence. Beyond these, several specific techniques reduce contamination risk.
UV irradiation is used to decontaminate PCR hoods and surfaces. UV light at 254 nm damages DNA by inducing thymine dimer formation, rendering the DNA non-amplifiable. A typical decontamination cycle runs for 15–30 minutes. UV irradiation only affects surfaces directly exposed to the light; shadowed areas are not decontaminated. The hood interior should be wiped clean before UV treatment.
Chemical decontamination uses oxidizing agents to destroy DNA. Sodium hypochlorite (bleach) at 10% concentration is effective but corrosive. Commercial DNA decontaminants such as DNAZap or DNA Away contain proprietary formulations that degrade nucleic acids without damaging equipment. These are applied to benchtops, pipettes, and thermal cycler surfaces.
Enzymatic digestion with DNA-degrading enzymes is an alternative for heat-sensitive equipment. DNase I can be applied to surfaces and allowed to incubate, but it is less reliable than chemical methods because it requires specific buffer conditions and is inhibited by contaminants.
Physical barriers include filter tips, which block aerosol transfer, and dedicated lab coats, which prevent DNA from clothing from reaching samples. Gloves should be changed frequently, particularly after handling samples or amplified products.
Primer design can mitigate contamination effects. Primers that span intron-exon boundaries in genomic DNA will not amplify contaminating genomic DNA from the researcher, since the intronic sequences are absent from cDNA. Similarly, using primers specific to the target organism rather than conserved sequences reduces the risk of amplifying environmental DNA.
PCR Zone Troubleshooting
False Positives
A false positive is a positive signal in a sample that does not actually contain the target sequence. The most common cause is amplicon contamination. When false positives appear, the first step is to examine the controls. If the negative control (water instead of template) shows a band or a fluorescent signal, contamination is present.
The troubleshooting sequence for false positives is:
- Repeat the experiment with fresh reagents, fresh water, and fresh tips.
- If the negative control is still positive, the contamination is likely in the reagents or the environment.
- Decontaminate all surfaces in Zones 1 and 2 with 10% bleach, followed by 70% ethanol.
- Irradiate the PCR hoods with UV for 30 minutes.
- Replace all reagents, including water, buffer, dNTPs, and primers.
- If the problem persists, the contamination may be in the thermal cycler or in the pipettes.
A systematic approach is essential. Changing one variable at a time—reagents, then surfaces, then equipment—identifies the source without wasting time.
Negative Control Issues
A negative control that shows amplification indicates contamination, but a negative control that fails to show amplification when the positive control also fails indicates a different problem: the reaction itself is not working.
Common causes of failed reactions include:
- Inactive polymerase: Taq polymerase loses activity with repeated freeze-thaw cycles or prolonged storage at room temperature.
- Incorrect annealing temperature: If the annealing temperature is too high, primers will not bind; if too low, non-specific products form. The optimal annealing temperature is typically 3–5°C below the melting temperature (Tm) of the primers. See Annealing Temperature Steel for a detailed discussion of annealing temperature optimization.
- Inhibitors in the template: Phenol, ethanol, or EDTA carried over from DNA extraction can inhibit polymerase activity.
- Wrong MgCl₂ concentration: Magnesium is a required cofactor for Taq polymerase. Too little magnesium prevents amplification; too much promotes non-specific products.
Smearing or Non-Specific Bands
Smearing on an agarose gel indicates non-specific amplification or degraded template DNA. The troubleshooting steps are:
- Check template quality: Run the template on a gel to verify it is intact. Degraded DNA produces smears because the polymerase amplifies from random break points.
- Increase annealing temperature: Higher annealing temperatures increase specificity by requiring more precise primer-template matching.
- Reduce cycle number: Excessive cycling (beyond 35–40 cycles) amplifies non-specific products that appear after the exponential phase has plateaued.
- Add DMSO or betaine: These additives reduce secondary structure in GC-rich templates and can improve specificity.
- Use hot-start polymerase: Hot-start Taq is inactive at room temperature and only becomes active after an initial denaturation step at 95°C. This prevents primer dimer formation and non-specific extension during reaction setup.
Zone design helps diagnose these issues. If smearing appears only in samples processed in Zone 2 but not in the positive control, the problem is likely template quality or sample-specific inhibitors. If smearing appears in all reactions including the positive control, the problem is in the master mix or the cycling conditions.
Methods to Monitor PCR Zone Integrity
Wipe Tests
A wipe test is a simple, effective method to verify that surfaces in clean zones are free of contaminating DNA. The procedure is:
- Wear fresh gloves.
- Moisten a sterile swab or a small piece of filter paper with nuclease-free water or sterile saline.
- Wipe a defined area of the surface to be tested—typically 10 cm × 10 cm.
- Place the swab in a tube containing PCR master mix.
- Run the PCR with primers specific to the target sequence of your assay.
- Run the products on a gel or analyze by qPCR.
If the wipe test shows amplification, the surface is contaminated and must be decontaminated. Wipe tests should be performed regularly—weekly in active laboratories, and immediately after any suspected contamination event.
Wipe tests can also be performed with generic primers that amplify conserved sequences, such as 16S rRNA primers, to detect any bacterial or fungal DNA contamination. This is particularly useful for detecting exogenous DNA contamination from environmental sources.
Environmental Monitoring
Environmental monitoring extends beyond surface testing to include air sampling and reagent testing.
Air sampling involves exposing open Petri dishes containing culture medium or open tubes containing PCR master mix to the laboratory air for a defined period (typically 1–4 hours). The tubes are then capped and subjected to PCR. If amplification occurs, airborne DNA is present. This test is particularly relevant in Zone 1, where the master mix is prepared.
Reagent testing involves running a PCR with each new batch of reagents—water, buffer, dNTPs, primers—using the reagent as the template. This detects contamination introduced during manufacturing or storage. A new batch of reagents should be tested before it is used for actual experiments.
Positive and negative controls are the most fundamental monitoring tools. Every PCR run should include:
- A positive control: a known template that should amplify successfully.
- A negative control: water or buffer instead of template, which should not amplify.
- A no-template control (NTC): master mix with water added in place of template, processed through the entire workflow.
The NTC is the most sensitive indicator of contamination because it contains all reaction components except template. If the NTC amplifies, contamination is present somewhere in the workflow.
Common Pitfalls in PCR Zone Management
Equipment Sharing
The most common mistake in PCR zone management is sharing equipment between zones. A pipette used in Zone 3 for loading gels carries amplicon DNA on its barrel and in its internal mechanisms. If that pipette is used in Zone 1 to prepare master mix, the amplicons are introduced directly into the reaction.
This mistake often occurs because laboratories have limited budgets and researchers are reluctant to purchase multiple sets of pipettes. However, the cost of a dedicated pipette set is trivial compared to the cost of repeated failed experiments. If dedicated pipettes are not available, the alternative is to use filter tips exclusively and to decontaminate pipettes with 10% bleach between uses—but this is a poor substitute for physical separation.
Waste Disposal
Improper waste disposal is another common pitfall. Used tips, tubes, and gels from Zone 3 contain high concentrations of amplicon DNA. If these items are disposed of in shared waste containers that are also used for Zone 1 or Zone 2 waste, the amplicons can spread.
The solution is to maintain separate waste containers for each zone. Zone 3 waste should be autoclaved or treated with bleach before disposal. Gels should be placed in dedicated containers and not allowed to dry on benchtops, where they can release DNA as they dehydrate.
Glove and Lab Coat Changes
Gloves are a major vector for contamination. A researcher who touches a tube containing amplified product in Zone 3, then walks to Zone 2 and touches a sample tube, transfers amplicons directly. Gloves should be changed:
- When entering a new zone.
- After handling samples or amplified products.
- After touching surfaces that may be contaminated (door handles, keyboards, phones).
- Whenever gloves are visibly soiled.
Lab coats should be dedicated to each zone. A lab coat worn in Zone 3 accumulates amplicon DNA on its sleeves and front. Wearing that coat into Zone 1 spreads the contamination. Ideally, each zone has its own lab coat, color-coded to prevent mix-ups.
Additional Pitfalls
- Opening tubes in the wrong zone: A tube containing amplified product must never be opened in Zone 1 or Zone 2. Even the exterior of a closed tube can carry amplicons.
- Using non-filter tips: Non-filter tips allow aerosolized liquid to contact the pipette barrel, contaminating it for all future uses.
- Skipping UV decontamination: The UV lamp in the PCR hood is not decorative. It should be turned on whenever the hood is not in use.
- Storing products in clean zones: Amplified products must be stored in Zone 3, never in the refrigerator or freezer used for reagents or samples.
- Ignoring the thermal cycler: The thermal cycler is often overlooked during decontamination. Its block and lid should be wiped with 10% bleach or a commercial decontaminant regularly.
Summary and Best Practices
Quick Checklist
- [ ] Zone 1 contains only reagents, never template DNA.
- [ ] Zone 2 is used only for sample processing and template addition.
- [ ] Zone 3 is used only for amplification and post-PCR analysis.
- [ ] Workflow is unidirectional: Zone 1 → Zone 2 → Zone 3.
- [ ] Dedicated pipettes and equipment in each zone.
- [ ] Filter tips used in Zones 1 and 2.
- [ ] UV lamp in PCR hood is turned on when hood is not in use.
- [ ] Gloves changed when moving between zones.
- [ ] Lab coats dedicated to each zone.
- [ ] Separate waste containers for each zone.
- [ ] Negative controls included in every PCR run.
- [ ] Wipe tests performed regularly.
- [ ] Thermal cycler decontaminated regularly.
- [ ] Amplified products never returned to clean zones.
Frequently Asked Questions
What is a PCR zone?
A PCR zone is a physically separated area of the laboratory designated for a specific stage of the PCR workflow. The standard setup uses three zones: reagent preparation, sample preparation, and amplification/post-PCR analysis. Each zone has dedicated equipment and supplies, and materials move between zones in one direction only—from clean to dirty.
Why are PCR zones important?
PCR zones prevent contamination of reactions with amplified DNA from previous experiments. PCR is extraordinarily sensitive, detecting as few as 10–100 copies of a target sequence. A single aerosol droplet containing amplified product can produce false positives in every subsequent reaction. Physical separation prevents this by ensuring that amplicons never enter the areas where reagents and samples are handled.
How many PCR zones are typically used?
Three zones are standard: Zone 1 for reagent preparation, Zone 2 for sample preparation, and Zone 3 for amplification and post-PCR analysis. Some laboratories use a two-zone setup (pre-PCR and post-PCR) for simple applications, while high-throughput facilities may use additional zones for DNA extraction or library preparation. The three-zone model is the most common and is recommended for teaching laboratories.
What is the workflow in PCR zones?
The workflow is unidirectional: prepare the master mix in Zone 1, add template DNA in Zone 2, and perform amplification and analysis in Zone 3. Personnel, equipment, and waste move in the same direction. Never return materials from Zone 3 to Zones 1 or 2. This one-way flow ensures that amplified products cannot contaminate the reagents or samples.
What are common sources of PCR contamination?
The most common sources are amplicons from previous reactions, sample-to-sample cross-contamination through shared pipettes, and exogenous DNA from the environment or the researcher. Amplicon contamination is the most dangerous because amplified products are present in enormous quantities and persist on surfaces for weeks. Skin cells shed by researchers contain genomic DNA that can contaminate reactions targeting human genes.
How can I troubleshoot PCR contamination?
Start by examining the controls. If the negative control shows amplification, contamination is present. Decontaminate all surfaces with 10% bleach followed by 70% ethanol, irradiate the PCR hoods with UV for 30 minutes, and replace all reagents. If the problem persists, test individual components—water, buffer, primers, dNTPs—by running each as a template in a PCR. Wipe tests can identify contaminated surfaces. For persistent contamination, see PCR Specimen Contamination Is Rare for a discussion of when contamination is and is not the likely explanation for unexpected results.
What is a wipe test in PCR zones?
A wipe test is a monitoring procedure that detects DNA contamination on surfaces. A sterile swab is moistened with nuclease-free water, wiped across a defined area of the surface, and then placed in a PCR reaction. If the reaction amplifies, the surface is contaminated. Wipe tests should be performed regularly—weekly in active laboratories—and after any suspected contamination event.
Can I use the same pipette in different PCR zones?
No. Pipettes must be dedicated to a single zone. A pipette used in Zone 3 carries amplicon DNA on its barrel and internal surfaces. Using that pipette in Zone 1 introduces the amplicons directly into the master mix. If dedicated pipettes are not available, use filter tips exclusively and decontaminate the pipette with 10% bleach between uses—but this is a poor substitute for physical separation.
Key Takeaways
- PCR zones are physically separated areas for different stages of the PCR workflow: reagent preparation (Zone 1), sample preparation (Zone 2), and amplification/post-PCR analysis (Zone 3).
- The unidirectional workflow—clean to dirty, never reverse—is the fundamental principle that prevents amplicon contamination.
- Amplicon contamination from previous reactions is the most common cause of false positives and is prevented by physical separation, dedicated equipment, and UV irradiation.
- Filter tips, dedicated lab coats, and frequent glove changes are essential preventive measures.
- Negative controls and wipe tests are the primary tools for monitoring zone integrity and detecting contamination.
- Common pitfalls include sharing equipment between zones, improper waste disposal, and neglecting to change gloves when moving between zones.
- For a deeper understanding of the amplification process itself, review Polymerase Chain Reaction and PCR Explained.
Further Reading
- Shiromoto Y et al. Increased migratory activity and cartilage regeneration by superficial-zone chondrocytes in enzymatically treated cartilage explants. BMC musculoskeletal disorders. 2022. PubMed 35296296
- Bartsch MS et al. The rotary zone thermal cycler: a low-power system enabling automated rapid PCR. PloS one. 2015. PubMed 25826708
- Yonezumi M et al. Detection of AP12-MALT1 chimaeric gene in extranodal and nodal marginal zone B-cell lymphoma by reverse transcription polymerase chain reaction (PCR) and genomic long and accurate PCR analyses. British journal of haematology. 2001. PubMed 11736940
- Chen K et al. Pregnancy Zone Protein Serves as a Prognostic Marker and Favors Immune Infiltration in Lung Adenocarcinoma. Biomedicines. 2023. PubMed 37509617