Category: 3. Business

Later stages for some products include one in which the crude extract is purified, with fats, waxes, lipids, and other solids filtered out. Other products cook for 24 to 36 hours in a vacuum oven to purge away residual solvent, the pressure inside the oven lowered so that the solvent evaporates without any of the good stuff boiling off.

Using solvents isn’t the only way to make an extract. Raw Garden sends a small amount of its harvest to a partner facility, where it’s turned into a hashish-like product called rosin via a simpler process, using only ice water, heat, and pressure. But hydrocarbon extraction is scalable and highly efficient: Raw Garden’s facility processes around 1,200 pounds of cannabis a day, and has plans to expand.

This isn’t to say there’s no art to it. A concentrate’s consistency—that is, whether the live resin turns into something creamy or crispy or oily—results from the strain one starts with, as well as small, inspired interventions during extraction. What if we whipped the extract before purging it? What if we cured it so that crystals form? Extract bound for vape cartridges sometimes involves an additional step, in which terpenes are evaporated and collected in a distillation column, then selectively reinserted to achieve specific scent and flavor profiles. In Raw Garden’s vape lab, a colorful aroma wheel shows a hundred-plus fragrances one might allegedly encounter in cannabis, like apricot, sage, pine tar, and espresso. “We’re taking aromatic compounds from plants,” says vice president of agricultural operations Casey Birthisel. “There’s a lot here that’s parallel to the perfume industry.”

Some medical professionals see more alarming parallels, however, to drugs ostensibly harder than cannabis. The sky-high potency of concentrates has raised red flags, as multiple epidemiological studies have found correlations between their frequent use and increased risks of psychosis and cannabis use disorder, a form of dependence. Those risks seem particularly acute for teenagers. Colorado and Washington, the first states to legalize recreational pot, are among the states where bills to limit THC potency have been introduced, then rejected or withdrawn amid industry pushback.

Meanwhile, according to analyst Adams, sales of marijuana flower made up about 70 percent of the recreational market when the first legal retailers opened in Colorado in 2014. Today, according to point-of-sale data from Adams and market research firm BDSA, that number has dropped to 40 percent. In the same span, sales of vaping and dabbing products have climbed from around 15 percent of the legal market to 32 percent, though the pace of that growth now seems to be slowing.

Using data from nearly 3.7 million Chinese physicians spanning 11 years, we found that between 2011 and 2021, 19.4% of physicians changed workplace at least once, and the national annual physician turnover rate increased from 1.6 to 4.4%. Geographically, physician turnover in China tended to favor more economically developed regions, such as the eastern region, urban areas, and provincial capital cities. Institutionally, physician turnover between different types of institutions demonstrated reciprocal exchanges with nearly balanced volumes, but there has been a growing appeal for primary care physicians. Younger physicians, those with higher degrees, and those with senior professional titles were more likely to change their workplaces. Non-permanent employment contracts, lower income, heavy workload, and working in rural areas or for a primary care institution were also risk factors for physician turnover.

Given the limited nationwide research on physician turnover, we identified only one study applied comparable definition of turnover in U.S. reporting national physician turnover rates using Medicare billing data, which increased from 3.7% (2010) to 4.2% (2020). Since 2014, the rate stabilized above 4%, peaking at 4.3% in 2018 [24]. This study reported similar level of national turnover rate but a more significant increase over the past decade. According to a previous survey conducted in 2013 across 11 western Chinese provinces, approximately 29.1% of the 5046 rural health workers indicated intentions to leave [25]. Their results were higher than our finding of 19.4%, which can be attributed to the fact that turnover intentions are generally higher than actual turnover [26]. Furthermore, their study participants came from the western region and rural areas, which were found to have higher turnover risk in this study. Monitoring the long-term dynamics of physician turnover in China is necessary to determine whether the rate will continue to rise or stabilize and whether it will be influenced by relevant policies.

Our analysis identified increased NTR in primary care institutions. In comparison, a survey of Chinese primary care physicians in 2005 reported that over 8% of health workers left primary care institutions annually, with the majority moving to higher level healthcare facilities [27]. Such improvements were most likely attributable to China’s substantial investments in primary care institutions in underserved areas [17]. Our findings indicated that economically developed regions, such as eastern China and urban areas, demonstrated stronger attractiveness to mobile physicians, which is consistent with research findings from other countries. A 2015 study of Australian general practitioners found a net turnover trend toward major cities [28], while another investigation into Australian primary care physician retention also identified remoteness as a critical factor influencing workforce turnover [29]. Similarly, a nationwide study of all general practices in the UK between 2007 and 2019 revealed that practices in the most deprived areas had higher turnover rates [30]. In terms of the direction of turnover, the overall physician mobility is relatively consistent with the population flow. According to the national population census data released by China, from 2010 to 2021, the proportion of urban population increased by 14.2 percentage points. Guangdong province is the largest province in terms of physician turnover inflow and has also experienced a population increase of 21.7 million over the past decade. The northeast region, as a major turnover-outflow area, has seen a population decrease of 11.0 million.

Our findings indicate that 14.4% of physician turnover occurred between provinces during the study period, although this proportion is increasing. Similar patterns have been observed in studies from Australia, with just 10% of physician mobility occurring across states [28]. Besides, between 2011 and 2021, while some provinces experienced net turnover losses, the total number of physicians and physician density in all provinces of China increased significantly [16] due to substantial physician inflows during this period. Therefore, current physician turnover is unlikely to have a significant impact on the geographic distribution. However, future studies should quantify such impacts to mitigate potential adverse effects. In addition, given the declining trend in physician inflows, physician turnover may increasingly influence geographic distribution in China in the future.

This study also discovered several turnover circuits in the Beijing–Tianjin–Hebei urban agglomeration, the Sichuan–Chongqing urban agglomeration, and the Yangtze River Delta region (Shanghai, Jiangsu, Zhejiang, Anhui), which align to China’s regional coordinated development strategies [13]. These areas exhibit geographical proximity but disparities in socioeconomic development levels and medical service capacity. Under the framework of these strategies, standardized professional title evaluation systems and unified social security policies have been implemented across regions, ensuring continuity in benefits for mobile physicians and effectively reducing institutional barriers to talent exchange. Notably, regional collaborations have been significantly enhanced, such as jointly established regional medical centers and delivered telemedicine care, which may encourage the formation of turnover circuits. For instance, elite medical hubs in Beijing and Shanghai that construct regional medical centers usually require physicians to undertake rotational assignments of months in partner regions (e.g., Tianjin, Anhui), exposing them to the professional and living environments of less-developed areas, which has been found to be positive factor to foster the willingness to relocate and practice in underserved regions [31]. Conversely, physicians in less-developed areas gain access to joint training programs and academic exchanges, improving job satisfaction while creating pathways for career advancement to higher tier institutions. However, further research is needed to investigate the turnover patterns within these circuits, as well as the mechanisms for addressing or exacerbating the imbalanced allocation of medical resources.

This study explored the factors that influence physician turnover in China and found that younger physicians, those with higher levels of education, senior professional titles, lower income, and heavier workloads, as well as those working in rural areas or primary care medical institutions, were more likely to leave their current jobs. Previous studies on the factors influencing physician turnover in individual provinces in China or other countries [30, 32, 33], as well as studies on the factors influencing physician turnover intentions [11, 12, 34], have yielded similar results. Over the past decade, physician turnover in China has been characterized by competition for highly educated and senior professional-level talents in developed regions. Non-permanent employment contracts were found to be an important risk factor for physician turnover in this study, which is consistent with the findings of a study conducted in Hubei, China [35]. Physicians with permanent employment contracts are more likely to feel a greater sense of belonging and are more loyal to their workplace.

To the best of our knowledge, this is the first study to report turnover among 3.7 million Chinese physicians across the Chinese mainland over an 11-year period. We developed a cohort based on individual-level data, allowing us to not only quantify the level, trajectory, and characteristics of Chinese physician turnover but also to identify individual and institutional factors that influence physician turnover. However, this study has limitations. First, we define turnover rate as the first recorded job change between 2011 and 2021, ignoring job changes that some physicians may have experienced prior to 2011. Nonetheless, our findings suggest that physician turnover prior to 2011 was likely to be low and had little impact on our results. Second, although CHSI requires institutions to update physician information, such as education and professional titles on an annual basis, some institutions may fail to keep up with changes in a timely manner, potentially underestimating the proportion of physicians with higher education levels and senior professional titles in the retention group. However, as more medical institutions use the data collection system for personnel management, and many provinces use it as a qualification check for professional title evaluation, the impact of this issue on our results is being mitigated. Third, the lack of physician turnover causality data prevents differentiation between voluntary (e.g., career transitions) and involuntary turnover (e.g., layoffs), which, however, might require distinct policy interventions. Fourth, the data we used is collected for government management purposes and reported by institutions, with little information on individual physician characteristics, such as marital status and families, which could be potential confounding factors. Fifth, due to limited access to related data, we could not integrate social factors such as population mobility, demographic shifts, and regional healthcare demand patterns into consideration, which would have further enhanced the policy relevance of our findings.

In summary, China is experiencing a rising turnover rate. Future policies should pay more attention to central, northeastern regions, and rural areas while continue strengthening the primary care physician workforce. Effective intervention may prioritize young professionals and senior experts by ensuring competitive salary packages, and controlling work-related burnout—measures proven effective by multiple studies [36]. Although current mobility patterns may not yet significantly impact overall distribution, continuous monitoring is necessary to guide physician turnover. If physicians continue to concentrate in developed regions, it may increase the fiscal load on healthcare systems and reduce operational efficiency [37]. This study also aims to provide an actionable solution for monitoring nationwide physician mobility by longitudinally linking individual-level administrative data, potentially addressing research gaps in other countries. Finally, updated health workforce data are crucial for understanding the dynamic changes in medical human resources. This will support evidence-based policy advocacy, scientific workforce planning, and effective governance at the regional, national, and global levels.

Billionaire SpaceX, Tesla and X owner Elon Musk says he plans to sue Apple for not featuring X and its Grok artificial intelligence chatbot app in its top recommended apps in its App Store.

Musk posted the comments on X late Monday, saying, “Hey @Apple App Store, why do you refuse to put either X or Grok in your ‘Must Have’ section when X is the #1 news app in the world and Grok is #5 among all apps? Are you playing politics? What gives? Inquiring minds want to know.”

Grok is owned by Musk’s artificial intelligence startup xAI.

Musk went on to say that “Apple is behaving in a manner that makes it impossible for any AI company besides OpenAI to reach #1 in the App Store, which is an unequivocal antitrust violation. xAI will take immediate legal action.”

He gave no further details.

There was no immediate comment from Apple, which has faced various allegations of antitrust violations in recent years.

A federal judge recently found that Apple violated a court injunction in an antitrust case filed by Fortnite maker Epic Games.

Regulators of the 27-nation European Union fined Apple 500 million euros in April for breaking competition rules by preventing app makers from pointing users to cheaper options outside its App Store.

Last year, the EU fined the U.S. tech giant nearly $2 billion for unfairly favoring its own music streaming service by forbidding rivals like Spotify from telling users how they could pay for cheaper subscriptions outside of iPhone apps.

As of early Tuesday, the top app in Apple’s App Store was TikTok, followed by Tinder, Duolingo, YouTube and Bumble. Open AI’s ChatGPT was ranked 7th.

Delivery drones are so fast they can zip a pint of ice cream to a customer’s driveway before it melts.

Yet the long-promised technology has been slow to take off in the United States. More than six years after the Federal Aviation Administration approved commercial home deliveries with drones, the service mostly has been confined to a few suburbs and rural areas.

That could soon change. The FAA proposed a new rule last week that would make it easier for companies to fly drones outside of an operator’s line of sight and therefore over longer distances. A handful of companies do that now, but they had to obtain waivers and certification as an air carrier to deliver packages.

While the rule is intended to streamline the process, authorized retailers and drone companies that have tested fulfilling orders from the sky say they plan to make drone-based deliveries available to millions more U.S. households.

Walmart and Wing, a drone company owned by Google parent Alphabet, currently provide deliveries from 18 Walmart stores in the Dallas area. By next summer, they expect to expand to 100 Walmart stores in Atlanta; Charlotte, North Carolina; Houston; and Orlando and Tampa, Florida.

After launching its Prime Air delivery service in College Station, Texas, in late 2022, Amazon received FAA permission last year to operate autonomous drones that fly beyond a pilot’s line of sight. The e-commerce company has since expand its drone delivery program to suburban Phoenix and has plans to offer the service in Dallas, San Antonio, Texas, and Kansas City.

The concept of drone delivery has been around for well over a decade. Drone maker Zipline, which works with Walmart in Arkansas and the Dallas-Fort Worth area, began making deliveries to hospitals in Rwanda in 2016. Israel-based Flytrex, one of the drone companies DoorDash works with to carry out orders, launched drone delivery to households in Iceland in 2017.

But Wing CEO Adam Woodworth said drone delivery has been in “treading water mode” in the U.S. for years, with service providers afraid to scale up because the regulatory framework wasn’t in place.

“You want to be at the right moment where there’s an overlap between the customer demand, the partner demand, the technical readiness and the regulatory readiness,” Woodworth said. “I think that we’re reaching that planetary alignment right now.”

DoorDash, which works with both Wing and Flytrex, tested drone drop-offs in rural Virginia and greater Dallas before announcing an expansion into Charlotte. Getting takeout food this way may sound futuristic, but it’s starting to feel normal in suburban Brisbane, Australia, where DoorDash has employed delivery drones for several years, said Harrison Shih, who leads the company’s drone program.

“It comes so fast and it’s something flying into your neighborhood, but it really does seem like part of everyday life,” Shih said.

Even though delivery drones are still considered novel, the cargo they carry can be pretty mundane. Walmart said the top items from the more than 150,000 drone deliveries the nation’s largest retailer has completed since 2021 include ice cream, eggs and Reese’s Peanut Butter Cups.

Unlike traditional delivery, where one driver may have a truck full of packages, drones generally deliver one small order at a time. Wing’s drones can carry packages weighing up to 2.5 pounds. They can travel up to 12 miles round trip. One pilot can oversee up to 32 drones.

Zipline has a drone that can carry up to 4 pounds and fly 120 miles round trip. Some drones, like Amazon’s, can carry heavier packages.

Once an order is placed, it’s packaged for flight and attached to a drone at a launch site. The drone automatically finds a route that avoids obstacles. A pilot observes as the aircraft flies to its destinations and lowers its cargo to the ground with retractable cords.

Shakiba Enayati, an assistant professor of supply chain and analytics at the University of Missouri, St. Louis, researches ways that drones could speed the delivery of critical health supplies like donated organs and blood samples. The unmanned aircraft offer some advantages as a transport method, such as reduced emissions and improved access to goods for rural residents, Enayati said.

But she also sees plenty of obstacles. Right now, it costs around $13.50 per delivery to carry a package by drone versus $2 for a traditional vehicle, Enayati said. Drones need well-trained employees to oversee them and can have a hard time in certain weather.

Drones also can have mid-air collisions or tumble from the sky. But people have accepted the risk of road accidents because they know the advantages of driving, Enayati said. She thinks the same thing could happen with drones, especially as improved technology reduces the chance for errors.

Woodworth added that U.S. airspace is tightly controlled, and companies need to demonstrate to the FAA that their drones are safe and reliable before they are cleared to fly. Even under the proposed new rules, the FAA would set detailed requirements for drone operators.

“That’s why it takes so long to build a business in the space. But I think it leads to everybody fundamentally building higher quality things,” Woodworth said.

Others worry that drones may potentially replace human delivery drivers. Shih thinks that’s unlikely. One of DoorDash’s most popular items is 24-packs of water, Shih said, which aren’t realistic for existing drones to ferry.

“I believe that drone delivery can be fairly ubiquitous and can cover a lot of things. We just don’t think its probable today that it’ll carry a 40-pound bag of dog food to you,” Shih said.

DoorDash said that in the areas where it offers drone deliveries, orders requiring the services of human delivery drivers also increase.

That’s been the experience of John Kim, the owner of PurePoke restaurant in Frisco, Texas. Kim signed on to offer drone deliveries through DoorDash last year. He doesn’t know what percentage of his DoorDash customers are choosing the service instead of regular delivery, but his overall DoorDash orders are up 15% this year.

Kim said he’s heard no complaints from drone delivery customers.

“It’s very stable, maybe even better than some of the drivers that toss it in the back with all the other orders,” Kim said.

For some, drones can simply be a nuisance. When the FAA asked for public comments on Amazon’s request to expand deliveries in College Station, numerous residents expressed concern that drones with cameras violated their privacy. Amazon says its drones use cameras and sensors to navigate and avoid obstacles but may record overhead videos of people while completing a delivery.

Other residents complained about noise.

“It sounds like a giant nagging mosquito,” one respondent wrote. Amazon has since released a quieter drone.

But others love the service. Janet Toth of Frisco, Texas, said she saw drone deliveries in Korea years ago and wondered why the U.S. didn’t have them. So she was thrilled when DoorDash began providing drone delivery in her neighborhood.

Toth now orders drone delivery a few times a month. Her 9-year-old daughter Julep said friends often come over to watch the drone.

“I love to go outside, wave at the drone, say ‘Thank you’ and get the food,” Julep Toth said.

___

AP Video Journalist Kendria LaFleur contributed from Frisco, Texas.

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Introduction and Objectives

Intrahepatic cholangiocarcinoma (ICC) is an aggressive malignant tumor with a high incidence rate and is often refractory to standard treatment, leading to a high frequency of recurrence and mortality.¹ Recent studies have indicated that hepatitis B virus (HBV) infection is a common cause of liver cirrhosis and hepatocellular carcinoma (HCC), and it is also an independent risk factor for ICC.^2,3 Consequently, HBV-associated ICC and HBV-associated HCC share similar clinicopathological features, such as elevated serum levels of alpha-fetoprotein (AFP) and similar tumor growth patterns, suggesting a common origin in bipotential progenitor cells.^4,5

The morbidity and mortality rates of ICC are rising. Although surgical resection is the primary treatment for early-stage ICC, it is only offered to 20–40% of patients with potentially operable disease.⁶ Furthermore, the 5-year survival rate for patients who experience recurrence after resection is only 21–35%.^7–9 Even those who undergo resection often face recurrence and poor prognoses, underscoring the urgent need for adjuvant therapies to reduce postoperative recurrence risks.

In 2006, the Society of Interventional Radiology issued a consensus statement on chemoembolization for hepatic malignancies. A meta-analysis of seven randomized controlled trials (RCTs) demonstrated that hepatectomy combined with postoperative adjuvant TACE significantly reduced the risk of death in HCC patients compared to hepatectomy alone.¹⁰ Adjuvant TACE is widely employed in postoperative patients with liver cancer who exhibit various high-risk recurrence factors, such as multiple tumor nodules, large tumor size, microvascular invasion, and satellite lesions.^11,12

Currently, there is no well-established adjuvant protocol for HBV-related ICC after R0 hepatectomy.¹² Previous studies have suggested that TACE can benefit patients with advanced and unresectable ICC.^13,14 However, only three studies have reported on the use of adjuvant TACE after radical resection for ICC. Shen et al found that postoperative TACE not only failed to delay tumor recurrence but also prolonged overall survival (OS) for patients with early tumor recurrence.¹⁵ Two other reports indicated that postoperative adjuvant TACE could improve survival rates for patients with advanced TNM stages (stages III or IV).^16,17 Notably, for patients with stage I ICC, postoperative TACE may enhance survival but also promote tumor recurrence.¹⁷

The concept of adjuvant TACE after hepatectomy for resectable ICC is not new; multiple studies spanning multiple decades have attempted to provide a definitive answer, but with little success and often conflicting results. TACE has been reported as an adjuvant therapy for HCC patients after curative resection. Based on the conflicting evidence from previous studies and the distinct biological characteristics of ICC compared to HCC, we hypothesized that adjuvant TACE would not demonstrate superiority in overall survival compared to resection alone, but might exert differential effects on recurrence depending on tumor stage. This study was designed as a superiority trial for the primary outcome of overall survival (OS). This study was designed as a superiority test for the primary outcome of overall survival. To clarify the role of postoperative adjuvant TACE on long-term OS and tumor recurrence after R0 liver resection for HBV-associated ICC, we conducted a retrospective study using propensity score weighting on patients without risk factors, treated with either resection followed by TACE or resection alone. Our objective was to evaluate the efficacy of adjuvant TACE on long-term recurrence and survival after curative resection, both before and after propensity score weighting analysis.

Patients and Methods

Ethical Approval

This retrospective study examined data collected from patients with solitary large ICC at the Eastern Hepatobiliary Surgery Hospital (EHBH). All patients were classified according to the AJCC TNM staging system and were in Child-Pugh class A or B. Written informed consent was obtained from all patients prior to surgery. The authors are accountable for all aspects of the work to ensure that any questions regarding the accuracy or integrity of the work are appropriately addressed. The study was conducted in accordance with the Declaration of Helsinki of 1975 (as revised in 2013) and was approved by the institutional ethics committee of The Third Affiliated Hospital of Naval Military Medical University. Histological evaluations of the tumor and liver parenchyma were performed using surgical or biopsy specimens. The committee waived the requirement for informed consent (both written and oral) from participants due to the retrospective nature of the study, which involved minimal risk and no intentional deception, and did not adversely affect patient rights and welfare.

Patients and Clinicopathological Factors

A total of 356 patients underwent surgical dissection for HBV-associated ICC at EHBH, The Third Affiliated Hospital of Naval Military Medical University (Shanghai, China) between January 2010 and February 2017. All patients in this study underwent R0 resection (excluding liver transplantation). Tumor staging was determined according to the 8th edition of the TNM classification system. The histological grade of tumor differentiation was assigned using the Edmondson grading system. R0 resection was defined as the complete removal of all tumors, with microscopic examination of margins showing no tumor cells. All pathological specimens were reviewed by two pathologists to confirm the diagnosis of ICC. Patients were enrolled based on the following criteria: (a) HBV-associated ICC; (b) liver function classified as Child-Pugh grade A or B; (c) no evidence of extrahepatic metastasis; (d) absence of extrahepatic disease. Exclusion criteria included: (a) past or present history of other concomitant malignant tumors; (b) recurrent ICC; or (c) having undergone radiofrequency ablation (RFA), microwave coagulation therapy (MCT), or cryoablation prior to the operation. Patients without clinical or imaging follow-up were excluded from analysis. Clinicopathological factors potentially related to survival and recurrence were selected for this study, including age, gender, HBsAg status, cirrhosis, tumor size, tumor differentiation, tumor location, carbohydrate antigen (CA) 19–9, alpha-fetoprotein (AFP), and carcinoembryonic antigen (CEA), using the upper limit of normal values from our hospital as cutoff points for laboratory parameters.

Treatment

Patients who underwent R0 resection were recommended for postoperative adjuvant TACE therapy. In addition to patient consent for adjuvant TACE, they were required to have a WHO performance status of 0–1, Child-Pugh class A or B, normal kidney function, white blood cell count ≥ 3.0 × 10^9/L, and platelet count ≥ 50 × 10^9/L. The first adjuvant TACE was performed within 6 to 8 weeks of liver resection, involving the injection of 3–5 mL of iodized oil emulsion with 5-fluorouracil (500 mg), hydroxycamptothecin (10 mg), and epirubicin (20 mg).

Follow-up

All patients who underwent R0 resection attended follow-up appointments one month after the operation, during which liver function tests, tumor markers, and abdominal ultrasounds were conducted every 2 to 3 months. In both groups, follow-up contrast-enhanced liver computed tomography (CT) or magnetic resonance imaging (MRI) was performed every 3 months or sooner if tumor recurrence was clinically suspected.

Statistical Analysis

Overall survival (OS) and recurrence-free survival (RFS) were used as primary endpoints. OS was defined as the interval from the date of liver resection to the date of the patient’s death or the date of the last follow-up. RFS was defined as the time interval until tumor recurrence or metastasis after the previous hepatectomy.

Baseline categorical and ordinal variables were expressed as numbers and percentages. Each variable’s standardized mean difference (SMD) was calculated to evaluate balance between groups, with an absolute value of ≤0.10 indicating good balance.¹⁸ OS and RFS were estimated using the Kaplan-Meier method and compared using the Log rank test. Univariate Cox proportional hazards regression analysis was employed to assess the effect of baseline variables on OS and RFS. Multivariable Cox regression models with stepwise selection algorithms were used to determine the association between TACE and OS or RFS, adjusting for significant variables identified in univariate analysis (P < 0.1).

To address potential imbalances in measured covariates between groups, we performed propensity score weighting (PSW) using inverse probability of treatment weights (IPTW) to construct a weighted cohort of patients with similar baseline characteristics. The propensity scores were estimated using a multivariable logistic regression model, regressing adjuvant TACE status on all baseline characteristics listed in Table 1. To mitigate instability caused by large weights in the IPTW models, we used trimmed weights. A robust sandwich estimator was also employed to assess the robustness of our results.¹⁹ In the subgroup analysis, Cox regression was utilized to calculate hazard ratios (HR) and 95% confidence intervals (CI). The assumptions of proportionality in the Cox regression models were verified graphically.

Table 1 Patient Demographics and Clinical Characteristics Before and After Propensity Score Weighting Using IPTW

Statistical analyses were conducted using SAS (version 9.4; SAS Institute) and R (version 4.1.2, R Foundation). A two-tailed P-value of less than 0.05 was considered statistically significant.

Results

Baseline Characteristics of Patients Before and After Propensity Score Weighting

A total of 356 patients were included in the study, among whom 77 (21.6%) received adjuvant TACE. The median follow-up period was 45.3 months (IQR: 29.7 to 59.2 months). The baseline characteristics of patients before and after IPTW are summarized in Table 1. Before IPTW, 83.1% of patients in the adjuvant TACE group and 72.8% in the non-TACE group were male. The adjuvant TACE group exhibited higher rates of elevated preoperative serum ALT (32.5% vs 23.3%), prolonged prothrombin time (13.0% vs 9.3%), cirrhosis (20.8% vs 15.8%), large tumor size (>5 cm) (59.7% vs 49.5%), multiple tumors (40.6% vs 25.5%), and microvascular invasion (13.0% vs 7.2%) compared to the non-TACE group. Poorly differentiated tumors, nerve invasion, and lymph node metastasis were more prevalent in the non-TACE group. Additionally, 11.8% (33/279) of patients in the non-TACE group and 5.2% (4/77) in the adjuvant TACE group were at TNM stage IV. In the IPTW-weighted population, the absolute SMD of all measured covariates was less than 0.10, indicating well-balanced baseline characteristics between the two groups after propensity score weighting.After propensity score weighting using IPTW, all baseline covariates were well-balanced between the TACE and non-TACE groups, with absolute standardized mean differences (SMD) <0.10 for all variables (Table 1), indicating successful mitigation of selection bias.

Specifically, the maximum absolute SMD after IPTW was 0.08 for tumor size, with all covariates achieving SMD <0.10 (detailed in Table 1), confirming adequate balance between treatment groups.

TACE and Mortality Risk

The 1-year, 3-year, and 5-year OS rates were 71.4% (95% CI: 52.7% to 83.8%), 47.5% (95% CI: 30.4% to 62.7%), and 38.4% (95% CI: 18.2% to 58.4%) in the TACE group, compared to 72.0% (95% CI: 63.0% to 79.3%), 45.8% (95% CI: 37.0% to 54.1%), and 38.0% (95% CI: 27.2% to 48.7%) in the non-TACE group. No significant difference in OS was found between the groups (P=0.629 by Log rank test, Figure 1). In the univariate analysis, TACE was not associated with mortality risk (HR=1.08, 95% CI: 0.78 to 1.51). The multivariable model identified two independent prognostic factors for OS, including CA19-9 (HR=1.40, 95% CI: 1.04 to 1.89) and TNM stage (II vs I, HR=3.04, 95% CI: 2.08 to 4.43; III vs I, HR=3.90, 95% CI: 2.69 to 5.66; IV vs I, HR=4.85, 95% CI: 3.08 to 7.64) (Table 2). The effect of TACE on OS remained non-significant after adjustment for these predictors (HR=0.90, 95% CI: 0.64–1.26; P=0.5396), similar to the results from the Cox proportional hazards model in the sample weighted by inverse probability of treatment using the propensity score (HR=0.88, 95% CI: 0.59 to 1.32; P=0.4253) (Table 3).

Table 2 Univariate and Multivariate Analysis of OS for Patients with Intrahepatic Cholangiocarcinoma in the Unweighted Population

Table 3 Univariate and Multivariate Analysis of RFS for Patients with Intrahepatic Cholangiocarcinoma in the Unweighted Population

Figure 1 Kaplan-Meier survival analysis of OS and RFS before and after propensity score weighting. (A) OS before PSW: Comparison between non-TACE (n=279) and adjuvant TACE (n=77) groups. No significant difference was observed (Log-rank P=0.629). The number at risk table indicates patients remaining in follow-up at 0, 12, 36, and 60 months. Gray bands represent 95% confidence intervals. Median follow-up: 45.3 months (IQR: 29.7–59.2). (B) RFS before PSW: Adjuvant TACE was associated with significantly increased recurrence risk (Log-rank P<0.001). The 1-, 3-, and 5-year RFS rates were 42.9%, 34.6%, and 24.6% (TACE) vs 63.4%, 47.8%, and 45.7% (non-TACE). (C) OS after IPTW: Non-TACE (n=75) vs TACE (n=77) groups. After adjusting for baseline imbalances (all SMD<0.10), OS remained comparable (Log-rank P=0.425). (D) RFS after IPTW: Persistent association between TACE and increased recurrence risk (Log-rank P=0.007; Cox HR=1.53, 95% CI: 1.02–2.28).

Subgroup analyses showed that TACE was not associated with OS in patients with different TNM stages (Supplementary Table 1).

TACE and Recurrence Risk

The 1-year, 3-year, and 5-year RFS rates were 42.9% (95% CI: 27.3% to 57.5%), 34.6% (95% CI: 19.6% to 50.0%), and 24.6% (95% CI: 9.3% to 43.7%) in the TACE group, compared to 63.4% (95% CI: 55.0% to 70.7%), 47.8% (95% CI: 39.5% to 55.7%), and 45.7% (95% CI: 35.8% to 53.2%) in the non-TACE group. TACE was associated with recurrence risk in the univariate analysis (P<0.001 by Log rank test, Figure 1B). Multivariable analysis identified four independent prognostic factors for ICC recurrence, including gender (HR=1.44, 95% CI: 1.05 to 1.97), satellite nodules (HR=1.57, 95% CI: 1.07 to 2.30), lymph node metastasis (HR=0.50, 95% CI: 0.30 to 0.84), and TNM stage (II vs I, HR=1.29, 95% CI: 0.84 to 1.97; III vs I, HR=4.35, 95% CI: 2.97 to 6.36; IV vs I, HR=2.24, 95% CI: 1.26 to 4.00) (Table 4). The effect of TACE on RFS remained significant after adjustment for these independent predictors (HR=1.93, 95% CI: 1.39 to 2.67; P<0.0001). After propensity score weighting, the Cox regression model indicated a significant difference in the risk of ICC recurrence between the TACE and non-TACE groups (HR=1.53, 95% CI: 1.02 to 2.28; P=0.0071).

Table 4 Comparison of OS and RFS for Patients with Intrahepatic Cholangiocarcinoma in the IPTW Weighted Population

Subgroup analyses revealed starkly divergent effects of TACE on recurrence risk across TNM stages: Stages I–II: No significant RFS benefit with TACE (Stage I: HR=1.44, 95% CI 0.85–2.44; Stage II: HR=1.09, 95% CI 0.58–2.03). Stages III–IV: Significantly increased recurrence risk (Stage III: HR=2.65, 95% CI 1.46–4.82; Stage IV: HR=5.77, 95% CI 1.69–19.69). However, the Stage IV subgroup included only 4 patients receiving TACE, resulting in wide confidence intervals; these findings require validation in larger cohorts.

When we categorized TNM stages into early (stages I and II) and advanced (stages III and IV) types, the reanalyzed data showed similar results, with no significant association between TACE and OS across different TNM stages, and distinct tendencies between TACE and RFS in the two main subgroups (Supplementary Table 2 and Figure 2).

Figure 2 Stage-stratified subgroup analysis of OS and RFS (E) OS in early-stage (I–II) ICC: Non-TACE (n=194) vs adjuvant TACE (n=55). No OS benefit with TACE (Log-rank P=0.138). (F) RFS in early-stage (I–II) ICC: No significant difference (Log-rank P=0.077), though a trend toward higher recurrence risk with TACE was observed (HR=1.27, 95% CI: 0.85–1.91). (G) OS in advanced-stage (III–IV) ICC: Non-TACE (n=85) vs TACE (n=22). TACE did not improve OS (Log-rank P=0.244). (H) RFS in advanced-stage (III–IV) ICC: TACE significantly increased recurrence risk (Log-rank P=0.001; HR=3.06, 95% CI: 1.78–5.26). The number at risk table shows earlier recurrence events in the TACE group. Consistent trends were observed in the forest plot of stage-specific hazard ratios (Supplementary Figure 1).

Conclusions

Therapeutic resection remains the only effective treatment; however, the prognosis after hepatectomy is poor, and recurrence is common.²⁰

As we know, HBV is a significant risk factor for hepatocellular carcinoma (HCC). Since hepatocytes and cholangiocytes share the same progenitor cells, it can be postulated that HBV may induce carcinogenesis in both cell types through similar mechanisms.²¹ Additionally, studies have demonstrated that HBV participates in the pathogenesis of ICC through inflammatory processes,^22,23 further supporting the potential role of HBV infection in cholangiocarcinoma development.

TACE has been reported as an adjuvant therapy for HCC patients following curative resection. A meta-analysis of six randomized controlled trials indicated that adjuvant TACE could improve survival in HCC patients with tumor vascular invasion or size > 5 cm.¹¹ For TACE, injecting cytotoxic drugs into the blood vessels to embolize those supplying the tumor results in strong cytotoxic and ischemic effects.^24,25 Although ICC does not typically appear hypervascular on CT or MRI studies, tumor blushes are often visible in angiography.²⁶

To our knowledge, there is no reliable evidence supporting the use of adjunctive TACE in ICC patients after R0 hepatectomy.^16,17,27 A limited number of prior studies have reported that adjuvant TACE improves OS in patients with advanced (stage III and IV) ICC tumors.^16,17 In our prospective study, we found that adjuvant TACE after radical surgery did not prolong OS or delay recurrence for patients with TNM stage I ICC.²⁸ The role of TACE following hepatectomy in treating HBV-associated ICC remains unclear.

Our retrospective study, encompassing a reasonably large patient cohort—some receiving resection followed by TACE and others receiving resection alone—suggests that adjuvant TACE does not improve overall survival or reduce recurrence. After adjusting for significant predictors, the effect of TACE on OS remained insignificant, consistent with the results from the Cox proportional risk model in the sample weighted by the inverse probability of treatment using propensity score. We performed analyses not only on the entire cohort but also on propensity-score matched pairs, as the control and TACE patients exhibited significant differences in some baseline characteristics. In subgroup analysis, the median OS of HBV-associated ICC patients was not significantly longer in the combined treatment group compared to the TACE monotherapy group before and after propensity score matching, indicating that HBV-associated ICC patients with varying TNM stages did not benefit from combination therapy.

One study reported that adjuvant TACE significantly reduced tumor recurrence and improved RFS and OS in HBV-related HCC patients at intermediate or high risk of recurrence.²⁹ Regarding ICC recurrence, patients with high nomogram scores may benefit from adjuvant TACE following liver resection.³⁰ Our present study also showed that the recurrence rate was significantly lower in patients who underwent liver resection alone. In this retrospective study, gender, lymph node metastasis, and TNM stage were identified as risk factors for early recurrence. After propensity score weighting, the Cox regression model indicated significant differences in ICC recurrence risk between the TACE and non-TACE groups. In subgroup analysis, TACE was not significantly associated with RFS in TNM stage I and II, but was positively associated with recurrence risk in TNM stage III and IV patients, suggesting that postoperative adjuvant TACE does not appear to reduce recurrence in those stages.

The paradoxical increase in recurrence risk with adjuvant TACE in advanced ICC (TNM III–IV) may be attributed to fundamental biological distinctions from HCC:1. Vascular and Drug Delivery Disparities. Unlike hypervascular HCC, ICC exhibits hypovascularity on imaging and irregular neovascularization histologically.²⁶ This limits chemotherapeutic drug penetration during TACE, creating sublethal drug concentrations that promote selection of resistant clones.⁵ Kim et al reported that ICC tumors showed significantly lower contrast enhancement on angiography compared to HCC (p<0.001).²⁶ 2.Hypoxia-Driven Pro-Metastatic Microenvironment. TACE-induced ischemia activates HIF-1α/VEGF pathways, which in ICC—but not HCC—recruits tumor-associated macrophages (TAMs) and myeloid-derived suppressor cells (MDSCs).³¹ These cells secrete IL-10 and TGF-β, fostering immunosuppression and metastatic niche formation.³¹ Zhou et al demonstrated 3-fold higher HIF-1α expression in ICC vs HCC after TACE (p=0.008).⁵ 3. Extratumoral Progression Mechanisms.Advanced ICC (Stage III: nodal involvement; Stage IV: distant spread) harbors micrometastases beyond TACE’s locoregional reach. Systemic inflammatory responses triggered by TACE—particularly in HBV-infected patients—may accelerate residual tumor growth via NF-κB/STAT3 signaling.³² Our Stage IV subgroup showed elevated CRP levels post-TACE (median ΔCRP=+18 mg/L, p=0.03). 4. HBV-Specific Synergy. HBV oncoproteins (eg, HBx) inhibit DNA repair and amplify oxidative stress from chemoembolization. In ICC cells, HBx upregulates PD-L1 by 2.1-fold after doxorubicin exposure (vs 1.3-fold in HCC),³³ potentially enabling immune escape during TACE-induced damage. These mechanisms align with clinical observations of elevated recurrence in TACE-treated advanced ICC^16,17 and underscore why HCC-derived TACE protocols may be inadequate for ICC.

Interpretation of stage-specific outcomes requires caution. While adjuvant TACE was associated with increased recurrence risk in TNM Stage III–IV subgroups, the Stage IV analysis included only 4 TACE-treated patients. The wide confidence interval (RFS HR: 1.69–19.69) reflects substantial statistical uncertainty. These findings must be considered exploratory and validated in larger cohorts.

This study has several limitations. First, it is a retrospective analysis, and the decision to conduct adjuvant TACE was not random. Well-designed randomized controlled trials are needed to confirm the results obtained in this study. Second, our research was conducted at a single institution, necessitating further validation in future studies. Third, the HBV infection rate is higher than in Western countries, which may introduce bias in clinical decision-making. Third, we observed that adjuvant TACE shortened progression-free survival (PFS) in patients with HBV-related ICC without affecting OS, since both OS and PFS were influenced by tumor characteristics and treatment methods. Fourth, subgroup analyses for TNM stages III–IV were underpowered, particularly for Stage IV where the TACE group had only 4 patients. The extremely wide confidence intervals (eg, RFS HR: 1.69–19.69) indicate low precision, and these results should not guide clinical decisions without further validation.Additionally, individual decisions regarding recurrence treatment may impact each patient’s prognosis. Therefore, further research is needed to clarify the effect of TACE on OS and PFS.

Reporting Checklist

The authors have completed the STROBE reporting checklist. The study was conducted in accordance with the Declaration of Helsinki of 1975 (as revised in 2013). The study was approved by the institutional ethics committee of The Third Affiliated Hospital of Naval Military Medical University. Histological evaluations of the tumor and liver parenchyma were carried out using surgical or biopsy specimens. The committee waived the need for informed consent (both written and oral) from participants because this was a retrospective observational study, involved very minimal risk to participants and did not include intentional deception; this waiver does not adversely affect the rights and welfare of the patients.

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.

Funding

This study was supported by the Natural Science Foundation of China (NSFC) grants (No.81372672,81672371), National Key Scientific Instrument and Equipment Development (2012YQ220113) and Scientific Research Project of Shanghai Science and Technology Commission (No.14411960200). Approval number: EHBHKY2022-K-029.

Disclosure

The authors report no conflicts of interest in this work.

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A key report Tuesday is expected to show that the rate of inflation increased in July, a potential indication that President Donald Trump’s tariffs are increasingly weighing on consumers.

Trump’s reaction to the report — especially if it shows inflation heating up — could be even more important after he fired the head of the federal agency behind the data.

Trump accused the Bureau of Labor Statistics’ top official, Erika McEntarfer, of allowing the agency to manipulate jobs data, an allegation that remains unsubstantiated. Her firing last week has raised alarms across Washington and among most mainstream economists, who say it could affect the integrity of the Labor Department’s data. While the data is routinely subject to revisions, there is no evidence that the changes were politically motivated.

A BLS spokesperson said Tuesday’s Consumer Price Index report, which measures the growth of prices paid by consumers, would not be affected by the ouster of McEntarfer. No official changes to its methodology have been announced in the past week.

The president is particularly keyed into the data now amid growing signs his unprecedented tariffs strategy is disrupting the economy. Even as he maintains that the trade duties are making the U.S. “strong and rich,” recent job growth has been anemic and increasingly concentrated in a narrow set of sectors like health care and state and local government.

The impact on consumer prices looks to be even more pronounced. Tariffs are taxes collected by the government on imported goods, hundreds of billions of which flow into the U.S. each month.

There has been debate about who actually ends up footing the cost of the import taxes, which economists agree shows up as inflation. Analysts with Goldman Sachs now estimate that consumers paid approximately 22% of tariff costs through June. In a note to clients, they said that figure could climb to as much as 67% by year’s end as businesses and supply chains adjust to the new regime. In that scenario, a separate inflation measure preferred by the Federal Reserve would rise to 3.2% in December, well ahead of the central bank’s official 2% target, the analysts said.

Some economists are now raising the prospect that the tariffs are nudging the U.S. economy toward stagflation, where the job market weakens even as price growth accelerates.

This is considered one of the worst scenarios for the Federal Reserve, which is tasked by Congress with keeping both unemployment and the rate of inflation low. Fed Chair Jerome Powell has indicated that if it weren’t for Trump’s tariffs, the Fed would have lowered interest rates by now in order to make borrowing in the economy cheaper and thus help boost employment.

Under current conditions, with price pressures increasing, cutting rates becomes more difficult.

“In a stagflationary environment, it is dangerous to cut without clear evidence that inflation has peaked,” Bank of America economists wrote in a recent note to clients. In other words, lowering rates too soon risks further stoking inflation pressures by increasing overall economic activity.

Two of Trump’s Fed appointees have a different view. In remarks delivered Saturday, Michele Bowman, the Fed’s vice chair for supervision, said any inflationary impact from tariffs should be considered a “one-off,” and that excluding those effects reveals a pace of price growth that is much more subdued. Fed Governor Chistopoher Waller offered a similar view earlier this month.

“Standard central banking practice is to ‘look through’ such price-level effects as long as inflation expectations are anchored, which they are,” Waller said.

That view is not shared by Powell, who said it remains unclear whether the inflationary impact from tariffs will prove to be short-lived.

“It is also possible that the inflationary effects could instead be more persistent,” he said in congressional testimony in June. “Avoiding that outcome will depend on the size of the tariff effects, on how long it takes for them to pass through fully into prices, and, ultimately, on keeping longer-term inflation expectations well anchored.”

Some economists estimate it could take as long as 18 months for the tariffs’ impact to fully make their way through the economy.

“The bulk of the effects are still ahead of us,” Diane Swonk, chief economist at KMPG consulting firm, told the “TODAY” show.

Beyond tariffs, consumers continue to feel the pinch of high prices on a variety of fronts, something the president promised to address on the campaign trail last year. Ground beef prices are now at an an all-time high as droughts have devastated herd counts. Electricity prices, too, are now at records, while homeowners insurance costs have also begun to reaccelerate. While inflation-adjusted weekly earnings ticked up last quarter, approximately 43% of workers saw their paychecks grow less than the cost of living as of June according to Indeed, with most concentrated at the low-to-middle end of the pay spectrum, according to Indeed.

A separate measure of current and future family financial situations tracked by the Conference Board research and consulting group deteriorated in July, with the share of consumers expecting a recession over the next 12 months still above the levels seen in 2024.

Last month, CNBC tracked price movements of 50 items at Walmart, finding some have increased by as much as 50%. Walmart said “pricing fluctuations are a normal course of business and are influenced by a variety of factors.”

Earlier this year, a Walmart executive was more direct about the impact tariffs were having.

“We’re wired for everyday low prices, but the magnitude of these increases is more than any retailer can absorb,” Chief Financial Officer John David Rainey told CNBC in May.

The case (44 pages/668 KB PDF) centres on Yoplait’s claim that Nutricia, a subsidiary of Danone, was passing off certain Icelandic-style ‘Skyr’ yoghurt products as Yoplait’s own, through allegedly confusing similar packaging and branding.

The High Court had previously granted an injunction restraining Nutricia from selling the disputed products in Ireland. However, Nutricia appealed the decision, challenging both the granting of the injunction and the form of the High Court’s order. While the Court of Appeal dismissed the appeal in substance, it upheld Nutricia’s challenge to the breadth of the order.

The High Court had restrained Nutricia not only from passing off its Skyr products as Yoplait’s, but also from placing on the Irish market any products that were “confusingly similar”. The Court of Appeal found this broader prohibition problematic, warning that it could expose Nutricia to contempt proceedings for conduct that would require separate judicial assessment.

In its judgment, the Court of Appeal emphasised that all parties are already bound by the general legal prohibition against passing off. To restate this obligation in an injunction, it said, would risk giving Yoplait an “unwarranted advantage” and could lead to enforcement complaints. Instead, the court limited the injunction to restraining Nutricia from passing off the specific Skyr products identified in the proceedings as those of Yoplait.

Laura Finn, intellectual property law expert at Pinsent Masons, said: “The decision highlights the importance of the court framing an order for injunctive relief in sufficiently precise terms so as not to expose a party to additional consequences for conduct that must be assessed separately or to offer a party an unfair advantage. It also confirmed established authority that survey evidence should not be relied upon in interlocutory applications.”

The court also addressed the issue of product similarity, particularly the shape and appearance of the yoghurt pots. The High Court found no material difference in the shape of the pots, contributing to its impression of confusing similarity. However, the Court of Appeal took a different view, noting that the “get up” of the pots was “quite distinct”. Despite this, the appellate court deferred to the trial judge’s subjective assessment, stating that it was not a “de novo” hearing and that the trial judge was entitled to assess similarity on the basis of his own impression. Accordingly, the Court of Appeal found that no error had been made.

Maureen Daly, intellectual property partner at Pinsent Masons said: “This judgment is a timely reminder for FMCG brands that visual similarity, even in a crowded market like yoghurts, can lead to legal difficulties. So, it is advisable to seek legal advice if in doubt”.

The creator of Fortnite, Epic Games, has won a partial victory in the Australian federal court against Apple and Google over restrictions in app stores and failing to allow for competition for in-app payment options, but it could be a long time before any changes are made in Australia.

Fortnite was kicked off the Google and Apple app stores in 2020 after Epic Games offered its own in-app payment system that bypassed the one used by the platforms, and cut out the fees Apple and Google receive for in-app payments.

Epic fought the ban by launching legal action against the two in multiple jurisdictions.

In the Australian cases, Epic Games alleged that Apple’s control over in-app purchases – preventing users from downloading apps outside the app store and preventing developers from running their own app store on iOS – were a misuse of market power, which substantially lessened competition in app development.

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The company also alleged Google harmed app developers and consumers in Australia by preventing choice over app distribution and in-app payments on Android devices.

Apple’s iOS and App Store are completely closed and controlled by Apple: if an app is on your phone, and there is a payment through that app, it has to go through Apple.

Similar rules apply on Google’s Android operating system for the Play Store, but Google also allows “side-loading” of apps – meaning apps installed directly on the phone without using the app store. It also allows for phone manufacturers such as Samsung to have their own app stores. Fortnite is still available on Android, but only through side-loading or through the Samsung store.

Each company charges fees for transactions in their app stores. Google Play charges a 15% fee for the first US$1m earned by developers each year, increasing to 30% above that. Apple developers pay a 15% fee if the revenue generated the previous year is lower than $1m, but pay 30% if they earn more than that.

Fees are common in the industry – Epic’s own store charges developers a 12% fee.

Epic argued that it should be able to offer its own store as competition to Apple’s store, and also offer alternative payment options within their app in the official Games Store.

Originally separate, the Australian cases were combined into a single monolith. Justice Jonathan Beach decided to hear the two cases and an associated class action at the same time to avoid duplication of witness evidence.

On Tuesday, Beach found that Apple had engaged in conduct likely to diminish competition, in breach of section 46 of the Competition and Consumer Act over preventing side-loading of apps on iOS, and by preventing developers using alternative payment methods for digital purchases.

For Google, it was found to breach section 46 of the Competition and Consumer Act for the similar Google Play billing system, and over Google’s Project Hug, a project that allegedly saw developers enticed to keep their apps in the Play Store.

Epic did not succeed in its other claims against the two companies.

In a post on X, Epic Games stated that its app store and Fortnite would come to iOS in Australia, but noted there were 2,000+ pages of findings that “we’ll need to dig into to fully understand the details”.

“This is a WIN for developers and consumers in Australia!”

A spokesperson for Google said the court recognised the “stark difference between Android’s open platform and Apple’s closed system” and welcomed the court’s rejection that Epic sought to run an app store within the app store.

However Google disagreed with “the court’s characterisation of our billing policies and practices, as well as its findings regarding some of our historical partnerships, which were all shaped in a fiercely competitive mobile landscape on behalf of users and developers”.

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“We will review the full decision when we receive it and assess our next steps,” the spokesperson said.

Powerful corporations ‘must play by the rules’

Any potential changes to the app stores and payment systems for Apple and Google in Australia are likely to be a long way off.

Beach delivered a summary of his judgment in the long-running case on Tuesday in a marathon hour and a half reading to cover the two Epic cases and two class actions, ahead of a full judgment being released with redactions to account for commercial sensitivities at a later date.

The Apple and Google judgments run to over 900 pages each, with the class action judgment running over 100 pages, Beach indicated.

The two class action cases were successful. Brought by app developers against Apple and Google, the cases focused on whether the companies had overcharged developers over app store purchases given their market dominance. The amount that developers would have otherwise been charged by the two companies, and the relief they will see from the case will be determined at a later hearing.

“This judgment is a turning point,” said Kimi Nishimura, principal at Maurice Blackburn Lawyers, the firm representing the app developers.

“It sends a clear message that even the most powerful corporations must play by the rules and respect the rights of consumers and developers alike.”

The case was heard over four months, finishing just over one year ago.

Fortnite has returned to the Apple app store in the US, and users can download via the Epic Games app store in Europe but the app still remains unavailable to download in Australia.

Apple was approached for comment.