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Transference of the embedded water, so-called virtual water, in the trade of crops among regions within a country is often neglected, leading to no information about the impacts on the water resources of exporting regions, especially if those regions are water-stressed or, worse, water-scarce. Virtual water trade, if not considered through the lens of sustainability, could lead to adverse effects on the water resources of an exporting region. Previous related studies have quantified virtual water trade among the states in the United States providing valuable insights; however, information for specific crop trade among counties, its water footprint at the county scale, the resultant virtual water flow among counties, and the sustainability assessment of those virtual water flows are lacking. In this study, we calculate the green and blue water footprint of cereal and milled grain products at the county level and then, using trade data, calculate the virtual water flows among the counties. Then, we assess the sustainability of the import by introducing unsustainable import fraction (UIF), which is the ratio of virtual water imported from water-scarce counties to that of total virtual water imported in the form of cereal and milled grains. Finally, we quantify the change in UIF from the 2007-2017 period. A few of the significant insights discovered through this analysis include: i) most of the cereal and milled grains trade is occurring among neighboring counties; ii) one-third of US counties import 75% or more virtual water from water scarce regions; iii) in 2017, Texas and Missouri were the largest importer and exporter, respectively; and iv) the number of counties importing cereals and milled grains from water-scarce counties increased from 2007 to 2017. Recommendations on alleviating the negative effects of the unsustainable import of cereal and milled grain are provided toward the end of the discussion.

Aim: To investigate the comparative effectiveness of trastuzumab emtansine (T-DM1) in a real-world population of HER2+ metastatic breast cancer (mBC) patients. Materials and methods: The Flatiron Health database was used to identify a cohort of HER2+ mBC patients who received first-line trastuzumab treatment and T-DM1 or lapatinib plus capecitabine as second-line treatment. Overall survival was compared between the two groups. Results: Three hundred and forty-five patients with HER2+ mBC received second-line T-DM1 and 65 lapatinib plus capecitabine. Overall survival was longer in patients treated with T-DM1 than those treated with lapatinib plus capecitabine (adjusted hazard ratio: 0.61; 95% CI: 0.41–0.91). Conclusion: Real-world data supports the effectiveness of T-DM1 in the second-line treatment of HER2+ mBC patients.

Irrigation expansion is often posed as a promising option to enhance food security. Here, we assess the influence of expansion of irrigation, primarily in rural areas of the contiguous United States (CONUS), on the intensification and spatial proliferation of surface freshwater scarcity. Our study shows that the rainfed to irrigation-fed (RFtoIF) transition of water-scarce croplands can impact scarcity in both transitioned and non-transitioned regions, with the magnitude of impact being dependent on multiple factors including local water demand, abstractions in the river upstream, and the buffering capacity of ancillary water sources to cities. Overall, RFtoIF transition will result in an additional 169.6 million hectares or 22% of the total CONUS land area facing moderate or severe water scarcity. Analysis of just the 53 large urban clusters with 146 million residents shows that the transition will result in 97 million urban population facing water scarcity for at least one month per year on average versus 82 million before the irrigation expansion. While these reported figures are subject to simulation uncertainties despite efforts to exercise due diligence, the study unambiguously underscores the need for strategies aimed at boosting crop productivity to incorporate the effects on water availability throughout the entire extent of the flow networks, instead of solely focusing on the local level. The results further highlight that if irrigation expansion is poorly managed, it may increase urban water scarcity, thus also possibly increasing the likelihood of water conflict between urban and rural areas.

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