Take CE/CME Test
Take CE/CME Test
Airway Diseases, Allergy, Asthma, Respiratory Tract Disorders CE/CME ACCREDITED Watch Time: 43 mins

touchMDT Strategies for the management of severe type 2 asthma: Expert insight into optimizing care

MDT specialists, plus a patient with severe asthma, discuss the disease burden and the role of biologics in the long-term management of severe T2 asthma

 Overview & Learning Objectives

Patient with severe type 2 asthma
Primary care physician, allergist and patient
Watch Video
Severe asthma: What are the daily challenges for patients and their families? Prof. Yawn, Prof. Agache, Ms O’Neal

Watch a primary care physician and an allergist share the latest definition of severe asthma, examine the impact of severe asthma on patients and families, and consider the associated treatment burden. Plus, see a patient’s personal account of living with severe asthma and their ensuing challenges.

Watch Video
Allergist, primary care physician and pulmonologist
Watch Video
The role of biologics in severe type 2 asthma: How do patients benefit? Prof. Agache, Prof. Yawn, Prof. Papi

Watch an allergist, a primary care physician and a pulmonologist review the latest data for approved biologics in severe type 2 asthma, highlight the biomarkers associated with disease and offer practical advice on biomarker screening, and share expert insights on the role of phenotyping and endotyping in treatment decision-making.

Watch Video
Pulmonologist, primary care physician, allergist and patient
Watch Video
Optimizing long-term management of patients with severe type 2 asthma: Evidence and clinical practice guidelines Prof. Papi, Prof. Yawn, Prof. Agache, Ms O’Neal

Watch a pulmonologist, a primary care physician and an allergist discuss the importance of the MDT, share the latest updates to key asthma guidelines, highlight the role of biologics, and offer practical insights for the long-term management of patients with severe type 2 asthma. Plus, a patient with severe asthma, Ms O’Neal, shares her personal experience of biologic treatment.

Watch Video
Primary care physician, allergist and patient

Watch a primary care physician and an allergist share the latest definition of severe asthma, examine the impact of severe asthma on patients and families, and consider the associated treatment burden. Plus, see a patient’s personal account of living with severe asthma and their ensuing challenges.
Expert Spotlight
Prof. Barbara Yawn
University of Minnesota, Minneapolis, MN, USA
Prof. Ioana Agache
Transylvania University, Brașov, Romania
Ms JoJo O’Neal
DeLand, FL, USA

Prof. Barbara Yawn, Prof. Ioana Agache, and Ms JoJo O’Neal define severe asthma, discuss the challenges of living with severe asthma for patients and their families, and highlight unmet needs for patients.

Listen on the go

 Learn more Back to MDT Hub Time: 12:40
 
Allergist, primary care physician and pulmonologist

Watch an allergist, a primary care physician and a pulmonologist review the latest data for approved biologics in severe type 2 asthma, highlight the biomarkers associated with disease and offer practical advice on biomarker screening, and share expert insights on the role of phenotyping and endotyping in treatment decision-making.
Expert Spotlight
Prof. Ioana Agache
Transylvania University, Brașov, Romania
Prof. Barbara Yawn
University of Minnesota, Minneapolis, MN, USA
Prof. Alberto Papi
University of Ferrara and University Hospital S. Anna, Ferrara, Italy

Prof. Ioana Agache, Prof. Barbara Yawn and Prof. Alberto Papi review the latest data for approved biologics in severe type 2 asthma, the role of phenotyping and endotyping in treatment decision-making, and share practical advice on biomarker screening.

Listen on the go

 Learn more Back to MDT Hub Time: 15:14
 
Pulmonologist, primary care physician, allergist and patient

Watch a pulmonologist, a primary care physician and an allergist discuss the importance of the MDT, share the latest updates to key asthma guidelines, highlight the role of biologics, and offer practical insights for the long-term management of patients with severe type 2 asthma. Plus, a patient with severe asthma, Ms O’Neal, shares her personal experience of biologic treatment.
Expert Spotlight
Prof. Alberto Papi
University of Ferrara and University Hospital S. Anna, Ferrara, Italy
Prof. Barbara Yawn
University of Minnesota, Minneapolis, MN, USA
Prof. Ioana Agache
Transylvania University, Brașov, Romania
Ms JoJo O’Neal
DeLand, FL, USA

Prof. Alberto Papi, Prof. Barbara Yawn, Prof. Ioana Agache and Ms JoJo O’Neal review key asthma guidelines and offer practical insights for the long-term management of patients with severe type 2 asthma.

Listen on the go

 Learn more Back to MDT Hub Time: 14:54
 
Back To Top
Overview & Learning Objectives
Overview

In this activity, MDT specialists involved in caring for patients with severe T2 asthma, plus a patient, share their perspectives on the challenges associated with severe asthma, the role of biologics and how to optimize the management of patients with severe T2 asthma.

This activity is jointly provided by USF Health and touchIME. read more

Target Audience

This activity has been designed to meet the educational needs of allergists, immunologists, primary care physicians and pulmonologists involved in the management of severe asthma.

Disclosures

USF Health adheres to the Standards for Integrity and Independence in Accredited Continuing Education. All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity.  The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Prof. Ioana Agache discloses: Speaker’s bureau fees from ALK, Merck, Mylan (relationships terminated); and AstraZeneca, Chiesi, Novartis and Sanofi Genzyme.

Prof. Alberto Papi discloses: Advisory board or panel fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Dompè, Edmond, Elpen, GSK, Mundipharma and Sanofi. Consultancy fees from AstraZeneca, Chiesi, GSK, Menarini, MSD, Novartis and Zambon.

Prof. Barbara Yawn discloses: Advisory board or panel fees from Novartis (relationship terminated), AstraZeneca, Boehringer Ingelheim, GSK and TEVA. Consultancy fees from AstraZeneca and Boehringer Ingelheim. Grant/research support from GSK.

Ms JoJo O’Neal has no interests/relationships or affiliations to disclose in relation to this activity.

Content reviewer

Karim Hanna, MD has no financial interests/relationships or affiliations in relation to this activity.

Touch Medical Director

Sola Neunie has no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu 

Accreditations

Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 1.0 AMA PRA Category 1 CreditTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu)

Advanced Practice Providers

Physician Assistants may claim a maximum of 1.0 Category 1 credits for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Date of original release: 27 January 2022. Date credits expire: 27 January 2024.

If you have any questions regarding credit please contact cpdsupport@usf.edu

Learning Objectives

After watching this activity, participants should be better able to:

  • Recognize the challenges associated with living with severe asthma
  • Discuss the role of biomarkers in guiding biologic treatment selection for patients with severe T2 asthma
  • Recall evidence-based guidance on the long-term management of patients with severe T2 asthma
Faculty & Disclosures
Prof. Ioana Agache

Transylvania University, Brașov, Romania

Ioana Agache is Professor of Allergy and Clinical Immunology at Transylvania University, Brașov, Romania. read more

Prof. Agache graduated with a medical degree from Carol Davila University, Bucharest and earned her PhD in internal medicine magna cum laude.

Her research in the field of asthma and allergy and clinical immunology focuses on asthma phenotypes and endotypes, immune modulation and immune tolerance, and integrated management of allergic diseases, with a special focus on primary care and community pharmacists.

Prof. Agache is Past President of the European Academy of Allergy and Clinical Immunology (EAACI) 2017–2019. She is a member of the Steering Committee and co-author of several international and European guidelines, such as ARIA (Allergic Rhinitis and its Impact on Asthma), EAACI Allergen Immunotherapy Guidelines and EAACI Food Allergy and Anaphylaxis Guidelines. Prof. Agache is Chair of the EAACI Guidelines on the Use of Biologics in Asthma and Allergic Diseases and of the EAACI Guidelines on Environmental Science in Allergy and Asthma.

She is editor of the Global Atlas of Asthma (2013 and 2020), Global Atlas of Allergy (2014), Global Atlas of Allergic Rhinitis and Chronic Rhinosinusitis (2015), Implementing Precision Medicine in Best Practices of Chronic Airway Diseases (2018); associate editor of Allergy and Clinical and Translational Allergy; and a member of the Editorial Board of the Journal of Allergy and Clinical Immunology.

Prof. Ioana Agache discloses: Speaker’s bureau fees from ALK, Merck, Mylan (relationships terminated); and AstraZeneca, Chiesi, Novartis and Sanofi Genzyme.
Prof. Alberto Papi

University of Ferrara and University Hospital S. Anna, Ferrara, Italy

Alberto Papi is Professor of Respiratory Medicine at the University of Ferrara, Italy, and Director of the Respiratory Unit of the Department of Emergency Medicine, S. Anna University Hospital, Ferrara, Italy. read more

Prof. Papi trained in respiratory medicine at the University of Parma, before spending 4 years in the UK as a clinical research fellow at the University of Southampton, where he is an honorary clinical lecturer. In 2015, he was made a fellow of the European Respiratory Society (FERS). He is also a member of the GOLD Science Committee.

Prof. Papi’s principal field of research is airway inflammation in asthma and chronic obstructive pulmonary disease (COPD), its molecular mechanisms and pharmacological modulation. He has taken particular interest in the role of respiratory viral infections in stable/exacerbated obstructive lung diseases, and the underlying molecular and immunological mechanisms. He has coordinated several studies, particularly in asthma and COPD, and he has published more than 430 original articles in peer-reviewed journals, and several publications in non-peer-reviewed journals. 

Prof. Alberto Papi discloses: Advisory board or panel fees from AstraZeneca, Boehringer Ingelheim, Chiesi, Dompè, Edmond, Elpen, GSK, Mundipharma and Sanofi. Consultancy fees from AstraZeneca, Chiesi, GSK, Menarini, MSD, Novartis and Zambon.
Prof. Barbara Yawn

University of Minnesota, Minneapolis, MN, USA

Barbara Yawn, MD MSc MSPH FAAFP, is a Family Physician and Clinical Researcher based in Minnesota, USA. read more

She began her medical practice in a rural community providing birth-to-death care for 14 years before moving to a larger city where she opened a primary care research department and served as a senior research scientist at the University of Minnesota Rural Health Research Center. 

Prof. Yawn’s work focuses on pragmatic and practice- and community-based research, using primary care and community-based evidence to inform guidelines and high-quality primary care. She has been active in the International Primary Care Research Group, served on the US Expert Panel for Asthma Guidelines and is director and founder of the Olmsted Medical Center Department of Research.

Prof. Yawn is also an adjunct professor of family and community health at the University of Minnesota and the chief science officer of the COPD Foundation. Her >400 peer-reviewed publications, three books and frequent national and international speaking appearances highlight her interest and expertise in primary care approaches to chronic respiratory diseases, among other common issues in primary care.

Prof. Barbara Yawn discloses: Advisory board or panel fees from Novartis (relationship terminated), AstraZeneca, Boehringer Ingelheim, GSK and TEVA. Consultancy fees from AstraZeneca and Boehringer Ingelheim. Grant/research support from GSK.
Ms JoJo O’Neal

DeLand, FL, USA

JoJo O’Neal, a radio host in Orlando, USA, was diagnosed with severe T2 asthma in 2004. read more

JoJo is the Founder and President of the Let’s Kick Asthma Foundation, Inc., a non-profit organization with a mission to educate people about asthma and help patients with asthma learn to live and breathe more easily. The organization offers support groups and outreach services to patients with asthma for assistance with their day-to-day needs.

JoJo is a past member of the Leadership Advisory Board of the American Lung Association in Florida.

Ms JoJo O’Neal has no interests/relationships or affiliations to disclose in relation to this activity.
Downloads

View and download resources from this activity to support your learning and share with colleagues

Download Slides
Download Slides
Download Slides
Download Slides
Download Slides
Download Slides
Register to touchRESPIRATORY for FREE
  • Peer-reviewed journals and expert opinions
  • Interactive CME and e-learning modules
  • Video conference highlights
Register For Free Now
This Activity Is Funded By:

An independent medical education grant from Regeneron Pharmaceuticals, Inc. and Sanofi Genzyme. This activity is jointly provided by USF Health and touchIME.

The information provided by this CME activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CME to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

This content is intended for healthcare professionals.

Date of original release: 27 January 2022. Date credits expire: 27 January 2024.

This content is intended for healthcare professionals only. Please confirm that you are a healthcare professional.

Accept Decline
CE/CME Test (1.0 Points) Close
CE/CME Test

To obtain the CME credit(s), please complete this post-test. Please complete and click to see your results and continue.
Question 1/5
Which of these are among the most common symptoms associated with severe asthma?
 Correct

A qualitative study using the St George’s Respiratory Questionnaire reported that 89% of patients with severe asthma experienced daily wheeze; up to 94% reported fatigue, exhaustion and poor sleep quality; and 56% reported a cough.1 

Most patients with asthma have comorbid rhinitis, and allergic rhinitis may be accompanied by ocular symptoms, including conjunctivitis.2

References

  1. McDonald VM, et al. Med J Aust. 2018;209(Suppl. 2):S28–33.
  2. Global Initiative for Asthma. 2021. Available at: https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf (accessed 13 December 2021).
Question 2/5
Your patient has severe type 2 eosinophilic asthma that is uncontrolled with high-dose ICS/LABA and add-on LAMA therapy. Due to poor access to biologics, your next step is to prescribe add-on low-dose OCS therapy. How would you advise your patient on one of the expected effects of OCS therapy?

ICS, inhaled corticosteroids; LABA, long-acting beta agonists; LAMA, long-acting muscarinic antagonist; OCS, oral corticosteroids; QoL; quality of life.
 Correct

Patients with severe uncontrolled asthma initially benefit from long-term OCS use due to better asthma control; however, as numerous side effects develop, improvements in quality of life become questionable. All long-term OCS therapies have been reported to increase the risk of comorbidities and complications.1 

OCS can affect the skin, skeleton, muscles, eyes, central nervous system, metabolism, cardiovascular system, immune system and the gastrointestinal system.1 

GINA recommends alternate-day treatment to minimize the side effects of OCS.2

Abbreviations

GINA, Global Initiative for Asthma; OCS, oral corticosteroids.

References

  1. Volmer T, et al. Eur Respir J. 2018;52:1800703.
  2. Global Initiative for Asthma. 2021. Available at: https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf (accessed 12 December 2021).
Question 3/5
Which of these biomarkers are suggestive of a type 2-high asthma endotype?

CO, carbon monoxide; FeNO, fractional exhaled nitric oxide.
 Correct

Type 2-high inflammation is diagnosed based on factors including elevated blood and sputum eosinophils, and FeNO levels.1 According to the GINA report, blood eosinophils ≥150 cells/µL, sputum eosinophils ≥2% and FeNO ≥20 ppb are indicative of type 2-high eosinophilic inflammation.1 Japanese asthma guidelines state that a blood eosinophil count ≥300–400 cells/µL is related to an increased risk of symptomatic asthma and poor asthma control; sputum eosinophils ≥2–3% suggest eosinophilic airway inflammation and FeNO >37 ppb may indicate worsening of asthma control.2

Abbreviations

FeNO, fractional exhaled nitric oxide; GINA, Global Initiative for Asthma; ppb, parts per billion.

References

  1. Global Initiative for Asthma. 2021. Available at: https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V2-WMS.pdf (accessed 9 December 2021).
  2. Nakamura Y, et al. Allergol Int. 2020;69:519–48.
Question 4/5
A 40-year-old male patient presents to you with persistent asthma symptoms and exacerbations that first arose several months ago. He is otherwise healthy, with no comorbidities or concomitant medications. You determine that his blood eosinophil count is 410 cells/μL, FeNO is 41 ppb and induced sputum neutrophil count is 45%. Which of these diagnostic considerations would you make to help determine the next steps?

FeNO, fractional exhaled nitric oxide; ppb, parts per billion; T2, type 2.
 Correct

The term asthma is now considered an umbrella diagnosis for several diseases with distinct mechanistic pathways (endotypes) and variable clinical presentations (phenotypes).

Asthma endotypes may be broadly regarded as T2-high or T2-low. The T2-high endotype includes the phenotypes early-onset allergic asthma (the predominant form in children), late-onset eosinophilic asthma and aspirin-exacerbated respiratory disease. The latter two phenotypes can be severe from onset, with more frequent exacerbations. Biomarkers for late-onset asthma are elevated blood/sputum eosinophil count and high FeNO.

T2-low phenotypes tend to be obesity- or smoking-related, or very-late onset (>50 years at onset).

Abbreviations

FeNO, fractional exhaled nitric oxide; T2, type 2.

Reference

Kuruvilla ME, et al. Clin Rev Allergy Immunol. 2019;56:219–33.

Question 5/5
Your 50-year-old female patient has uncontrolled, OCS-dependent, severe type 2 asthma. You decide to prescribe the anti-IL-4R⍺, dupilumab, as an add-on treatment. How would you advise your patient on the potential long-term treatment effects?

IL-4R⍺, interleukin 4 receptor alpha; OCS, oral corticosteroids; QoL, quality of life.
 Correct

TRAVERSE was a long-term dupilumab extension study in patients with moderate-to-severe or OCS-dependent severe asthma who had previously completed a dupilumab asthma study. Patients who previously received dupilumab experienced further improvements in exacerbation rate, asthma control and HR-QoL; blood eosinophils and total serum IgE levels also progressively decreased.

Abbreviations

IgE, immunoglobulin E; HR-QoL, health-related quality of life; OCS, oral corticosteroids.

Reference

Wechsler M, et al. Lancet Respir Med. 2021;doi: 10.1016/S2213-2600(21)00322-2. Online ahead of print.

Post Test Feedback Close
Step 1: Post CE/CME Test Feedback

Please note this feedback form is compulsory to complete your CE/CME evaluation

* = Mandatory Field

Please complete this short online feedback form.
Please indicate how well each statement met your expectations.
Accreditation Close
Accreditation

Please provide your details so that we can send you your certificate, which will be emailed to the address provided. All fields are required.

* = Mandatory Field
Your Accreditation Close
Your Accreditation

Thank you for your submission. Your certificate has been emailed to you.

Copied to clipboard!
accredited arrow-down-editablearrow-downarrow_leftarrow-right-bluearrow-right-dark-bluearrow-right-greenarrow-right-greyarrow-right-orangearrow-right-whitearrow-right-bluearrow-up-orangeavatarcalendarchevron-down consultant-pathologist-nurseconsultant-pathologistcrosscrossdownloademailexclaimationfeedbackfiltergraph-arrowinterviewslinkmdt_iconmenumore_dots nurse-consultantpadlock patient-advocate-pathologistpatient-consultantpatientperson pharmacist-nurseplay_buttonplay-colour-tmcplay-colourAsset 1podcastprinter scenerysearch share single-doctor social_facebooksocial_googleplussocial_instagramsocial_linkedin_altsocial_linkedin_altsocial_pinterestlogo-twitter-glyph-32social_youtubeshape-star (1)tick-bluetick-orangetick-red tick-whiteticktimetranscriptup-arrowwebinar Sponsored Department Location NEW TMM Corporate Services Icons-07NEW TMM Corporate Services Icons-08NEW TMM Corporate Services Icons-09NEW TMM Corporate Services Icons-10NEW TMM Corporate Services Icons-11NEW TMM Corporate Services Icons-12Salary £ TMM-Corp-Site-Icons-01TMM-Corp-Site-Icons-02TMM-Corp-Site-Icons-03TMM-Corp-Site-Icons-04TMM-Corp-Site-Icons-05TMM-Corp-Site-Icons-06TMM-Corp-Site-Icons-07TMM-Corp-Site-Icons-08TMM-Corp-Site-Icons-09TMM-Corp-Site-Icons-10TMM-Corp-Site-Icons-11TMM-Corp-Site-Icons-12TMM-Corp-Site-Icons-13TMM-Corp-Site-Icons-14TMM-Corp-Site-Icons-15TMM-Corp-Site-Icons-16TMM-Corp-Site-Icons-17TMM-Corp-Site-Icons-18TMM-Corp-Site-Icons-19TMM-Corp-Site-Icons-20TMM-Corp-Site-Icons-21TMM-Corp-Site-Icons-22TMM-Corp-Site-Icons-23TMM-Corp-Site-Icons-24TMM-Corp-Site-Icons-25TMM-Corp-Site-Icons-26TMM-Corp-Site-Icons-27TMM-Corp-Site-Icons-28TMM-Corp-Site-Icons-29TMM-Corp-Site-Icons-30TMM-Corp-Site-Icons-31TMM-Corp-Site-Icons-32TMM-Corp-Site-Icons-33TMM-Corp-Site-Icons-34TMM-Corp-Site-Icons-35TMM-Corp-Site-Icons-36TMM-Corp-Site-Icons-37TMM-Corp-Site-Icons-38TMM-Corp-Site-Icons-39TMM-Corp-Site-Icons-40TMM-Corp-Site-Icons-41TMM-Corp-Site-Icons-42TMM-Corp-Site-Icons-43TMM-Corp-Site-Icons-44TMM-Corp-Site-Icons-45TMM-Corp-Site-Icons-46TMM-Corp-Site-Icons-47TMM-Corp-Site-Icons-48TMM-Corp-Site-Icons-49TMM-Corp-Site-Icons-50TMM-Corp-Site-Icons-51TMM-Corp-Site-Icons-52TMM-Corp-Site-Icons-53TMM-Corp-Site-Icons-54TMM-Corp-Site-Icons-55TMM-Corp-Site-Icons-56TMM-Corp-Site-Icons-57TMM-Corp-Site-Icons-58TMM-Corp-Site-Icons-59TMM-Corp-Site-Icons-60TMM-Corp-Site-Icons-61TMM-Corp-Site-Icons-62TMM-Corp-Site-Icons-63TMM-Corp-Site-Icons-64TMM-Corp-Site-Icons-65TMM-Corp-Site-Icons-66TMM-Corp-Site-Icons-67TMM-Corp-Site-Icons-68TMM-Corp-Site-Icons-69TMM-Corp-Site-Icons-70TMM-Corp-Site-Icons-71TMM-Corp-Site-Icons-72