This content is for healthcare professionals only.

This activity is funded by an independent medical education grant from Alexion Pharmaceuticals.

This activity is jointly provided by USF Health and touchIME.

Faculty & Disclosures

Listen on the go

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

    Download Slides
    CORRECT!
    Next question
    Faculty & Disclosures
    Prof. Said Beydoun

    Keck School of Medicine of USC, Los Angeles, CA, USA

    Prof. Said R Beydoun is professor and division chief of neuromuscular medicine at the Department of Neurology at Keck Medicine of University of Southern California (USC), Los Angeles, CA, USA. Prof. Beydoun is also programme director of an ACGME-accredited Clinical Neurophysiology Fellowship. read more

    As a principal investigator, Prof. Beydoun has participated in multiple research clinical trials. His clinical and research areas of expertise in the field of neuromuscular medicine include: amyotrophic lateral sclerosis (ALS), myasthenia gravis, peripheral neuropathy, chronic inflammatory demyelinating polyneuropathy , multifocal motor neuropathy and transthyretin amyloid neuropathy.

    Prof. Beydoun has been published in several scientific journals on topics related to neuromuscular diseases. He is co-editor-in-chief of touchREVIEWS in Neurology. He is also an elected fellow of the American Academy of Neurology and a fellow of the American Association of Neuromuscular and Electrodiagnostic Medicine. Prof. Beydoun is a member of the medical/scientific advisory board of the Myasthenia Gravis Foundation of America and medical director of the Certified ALS Treatment Center of Excellence at Keck USC. He holds board certification by the American Board of Psychiatry and Neurology in Neurology, Clinical Neurophysiology, Neuromuscular Medicine and Pain Medicine.

    Prof. Said Beydoun discloses: Advisory board fees Alexion Pharmaceuticals, Alnylam Pharmaceuticals, Amylyx Pharmaceuticals, Argenx, Biogen, Ionis Pharmaceuticals, Mitsubishi Tanabe Pharma, Octapharma, Takeda and UCB; Grants/research support from Abcuro, Amylyx Pharmaceuticals, Genentech, Healey MGH, Regeneron Pharmaceuticals, Sanofi and UCB; Speaker’s bureau fees from Alexion Pharmaceuticals, Alnylam Pharmaceuticals, Amylyx Pharmaceuticals, Argenx Pharmaceuticals, Grifols and Takeda.
    Dr Pushpa Narayanaswami

    Beth Israel Deaconess Medical Center, Boston, MA, USA

    Dr Pushpa Narayanaswami is an associate professor of neurology at Harvard Medical School and vice-chair of clinical operations at the Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA. read more

    In her clinical practice, Dr Narayanaswami manages neuromuscular conditions, with special emphasis on myasthenia gravis, myopathies and muscular dystrophies. Her advocacy work seeks to incorporate health services research with healthcare policy to improve patient care.

    Dr Pushpa Narayanaswami is a fellow of the American Academy of Neurology. She is an associate editor for Muscle and Nerve, a member of the level of evidence team of Neurology and serves on the editorial board of Clinical Neuromuscular Disease. She is a member of the Board of Directors of the American Association of Neuromuscular and Electrodiagnostic Medicine, where she also chairs the Quality Improvement and Patient Safety Committee. She serves on the medical and scientific advisory board of the Myasthenia Gravis Foundation of America. She was part of the international panel that developed consensus guidelines for the management of myasthenia gravis. 

    Dr Pushpa Narayanaswami discloses: Advisory board fees from Alexion Pharmaceuticals, Argenx, Dianthus Therapeutics, Janssen and UCB; Consultancy fees from GSK; Grants/research fees from Alexion Pharmaceuticals; Financial support from Sanofi (relationship terminated); Stockholder in Momenta Pharmaceuticals, Pfizer and Viatris (relationship terminated).
    Prof. Heinz Wiendl

    Department of Neurology, University Hospital Münster, Münster, Germany

    Prof. Heinz Wiendl is professor of neurology and chair of the Department of Neurology at the University Hospital of Münster in Germany. read more

    Prof. Wiendl’s research focuses on inflammatory neurodegeneration and immune regulation and protection, as well as monitoring multiple sclerosis and its therapy. In 2017, he was appointed honorary professor at Sydney Medical School and in 2020, he received an honorary doctorate from the Medical Faculty of Mashhad, Iran.

    Prof. Wiendl is a member of numerous scientific and academic advisory boards and expert panels, including editorial boards of international scientific journals in the fields of neurology, neurosciences and immunology. 

    Prof. Heinz Wiendl discloses: Advisory board fees from Alexion Pharmaceuticals, Argenx, Bristol Myers Squibb, Janssen, Merck, Novartis and Sandoz; Consultant fees from Actelion, Argenx, BD, Biogen, EMD Serono, Fondazione, Gossamer Bio, Idorsia, Immunic Therapeutics, Immunovant, Lundbeck, Merck, NexGen, Novartis, PSI CRO, Roche, Sanofi and UCB; Grants/research support from Alexion Pharmaceuticals, Amicus Therapeutics, Argenx, Biogen, CSL Behring, F. Hoffmann-La Roche, Genzyme, Merck, Novartis, Roche and UCB.
    Back to Faculty
    touchNEUROLOGY touchNEUROLOGY
    Start activity
     
    Video Take CE/CME Test
    Neuroimmunology, Neuromuscular Diseases CE/CME accredited

    touchPANEL DISCUSSION
    A visually engaging discussion designed to emulate a ‘live’ panel experience and provide clinicians with practical expert insights to address their clinical challenges. Useful tips below will show how to navigate the activity. Close

    The complement system in NMOSD and MG: A target for therapeutic benefit?

    Useful tips
    • Downloads including slides are available for this activity in the Toolkit
    Learning Objectives

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

    • Describe the role of complement in the pathophysiology of NMOSD and MG
    • Evaluate markers of complement activation as diagnostic and prognostic biomarkers in NMOSD and MG
    • Discuss recently approved and experimental inhibitors of the complement system for the treatment of NMOSD and MG
    Overview

    In this activity, three experts discuss the evidence for complement involvement in neuromyelitis optica spectrum disorder (NMOSD) and myasthenia gravis (MG) pathogenesis, the markers of complement activation, as well as the latest data for complement therapeutics.

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

    Target Audience

    Neurologists (including neuromuscular disease specialists), immunologists (including neuro-immunologists) and ophthalmologists involved in the management of patients with neurological disorders, including NMOSD and MG.

    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. Said Beydoun discloses: Advisory board fees Alexion Pharmaceuticals, Alnylam Pharmaceuticals, Amylyx Pharmaceuticals, Argenx, Biogen, Ionis Pharmaceuticals, Mitsubishi Tanabe Pharma, Octapharma, Takeda and UCB; Grants/research support from Abcuro, Amylyx Pharmaceuticals, Genentech, Healey MGH, Regeneron Pharmaceuticals, Sanofi and UCB; Speaker’s bureau fees from Alexion Pharmaceuticals, Alnylam Pharmaceuticals, Amylyx Pharmaceuticals, Argenx Pharmaceuticals, Grifols and Takeda.

    Dr Pushpa Narayanaswami discloses: Advisory board fees from Alexion Pharmaceuticals, Argenx, Dianthus Therapeutics, Janssen and UCB; Consultancy fees from GSK; Grants/research fees from Alexion Pharmaceuticals; Financial support from Sanofi (relationship terminated); Stockholder in Momenta Pharmaceuticals, Pfizer and Viatris (relationship terminated).

    Prof. Heinz Wiendl discloses: Advisory board fees from Alexion Pharmaceuticals, Argenx, Bristol Myers Squibb, Janssen, Merck, Novartis and Sandoz; Consultant fees from Actelion, Argenx, BD, Biogen, EMD Serono, Fondazione, Gossamer Bio, Idorsia, Immunic Therapeutics, Immunovant, Lundbeck, Merck, NexGen, Novartis, PSI CRO, Roche, Sanofi and UCB; Grants/research support from Alexion Pharmaceuticals, Amicus Therapeutics, Argenx, Biogen, CSL Behring, F. Hoffmann-La Roche, Genzyme, Merck, Novartis, Roche and UCB.

    Content reviewer

    Niraja S. Suresh, MD, has no financial interests/relationships or affiliations in relation to this activity.

    Touch Medical Contributors

    Kathy Day 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 0.75 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 0.75 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: 17 August 2023. Date credits expire: 17 August 2024.

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

    This activity is CE/CME accredited

    To obtain the CE/CME credit(s) from this activity, please complete this post-activity test.

    Claim Credit
    Useful tips
    • Downloads including slides are available for this activity in the Toolkit

    You may also be interested in...

    touchIN CONVERSATION

    Individualizing long-term treatment and care in active MS: How are therapeutic sequencing options evolving to address unmet needs?

    This activity is CE/CME accredited
    LAUNCH ACTIVITY

    touchSATELLITE SYMPOSIUM

    Considering the complete picture in neuromyelitis optica spectrum disorder: Optimizing diagnosis and management to improve patient outcomes

    This activity is CE/CME accredited
    LAUNCH ACTIVITY

    CONFERENCE HUB

    Jerry Mendell, AAN 2021: Gene Therapies in the Treatment of Patients with Duchenne Muscular Dystrophy

    GO TO HUB
    thumbnail-12.png

    JOURNALS

    Biological Agents for Chronic Inflammatory Demyelinating Polyradiculoneuropathy

    GO TO ARTICLE
    Restless Legs Syndrome Awareness Week - Penn State Hershey Medical Center

    CONFERENCE HUB

    Restless Legs Syndrome Awareness Week – Penn State Hershey Medical Center

    GO TO HUB

    JOURNALS

    Maldistribution of Neurofilaments, Disease Pathogenesis, and Amyotrophic Lateral Sclerosis

    GO TO ARTICLE

    Topics covered in this activity

    Neuroimmunology / Neuromuscular Diseases
    REGISTER NOW FOR FREE ACCESS TO
    • 1000+ topical and insightful peer-reviewed journal articles
    • 100+ hours of bite-sized congress highlights
    • 10 major therapy areas packed with the latest scientific advances
    • 150+ specialties offering learn-on-the-go medical education
    • + Concise email updates and newsletters so you never miss out
    Register For Free Now
    This Activity Is Funded By:

    An independent medical education grant from Alexion Pharmaceuticals.
    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: 17 August 2023. Date credits expire: 17 August 2024.

    Claim Credit
    touchPANEL DISCUSSION
    The complement system in NMOSD and MG: A target for therapeutic benefit?
    0.75 CE/CME credit
    Question 1/5
    Which statement describes a key difference between the pathophysiology of NMOSD and MG?

    C, serum complement protein; CNS, central nervous system; MG, myasthenia gravis; NMJ, neuromuscular junction; NMOSD, neuromyelitis optica spectrum disorder.

    MG is usually mediated by AChR antibodies, which can be blocking, modulating or binding.1 Activation of the classical complement pathway occurs when the antibody binds to the AChR.2 This results in MAC formation and damage to the postsynaptic membrane.1 In NMOSD, complement activation leads to C5b-mediated MAC formation. The subsequent astrocyte cell death alongside C5a formation induces release of pro-inflammatory cytokines, leading to further cytotoxicity, demyelination and neuronal tissue damage.3

    Abbreviations

    AChR, acetylcholine receptor; C, serum complement protein; MAC, membrane attack complex; MG, myasthenia gravis; NMOSD, neuromyelitis optica spectrum disorder.

    References

    1. Dresser L, et al. J Clin Med. 2021;10:2235.
    2. Albazli K, et al. Front Immunol. 2020;11:917.
    3. Ponleitner M, Rommer PS. Wien Med Wochenschr. 2022. doi: 10.1007/s10354-022-00987-2.
    Question 2/5
    Your patient presents with fatigue, pain, stiffness/spasticity, bladder and bowel dysfunction, cognitive/emotional symptoms and visual disturbances. MRI scans reveal NMOSD-typical lesions and signs of ocular disease. What action would you take to make a definitive diagnosis of NMOSD?

    AQP4, aquaporin 4; MRI, magnetic resonance imaging; NMOSD, neuromyelitis optica spectrum disorder.

    In AQP4 positive disease, the presence of one of the six core clinical characteristics (LETM, optic neuritis, APS, symptomatic brainstem, diencephalic, or cerebral syndromes) with AQP4 antibodies is sufficient to make a diagnosis of NMOSD. Approximately 75% of patients have antibodies against AQP4. In seronegative cases, the criteria are more stringent and MRI requirements must also be fulfilled.

    Abbreviations

    APS, area postrema syndrome; AQP4, aquaporin 4; LETM, longitudinally extensive transverse myelitis; MRI, magnetic resonance imaging; NMOSD, neuromyelitis optica spectrum disorder.

    Reference
    Huda S, et al. Clin Med (Lond). 2019;19:169–76.

    Question 3/5
    You are considering treatment options for your patient who is showing symptoms characteristic of MG. How might a finding of a low AChR antibody titre guide your prognostic and diagnostic decision making?

    AChR, acetylcholine receptor; MG, myasthenia gravis.

    Diagnosis of MG should be made on a clinical basis, considering the clinical history and physical symptoms.1 Testing for AChR antibodies is very important to help define the disease pathophysiology and validate the diagnosis. While the specificity can be up to 95%, the risk of false positives means antibody testing alone should not be a confirmatory test.1 There is no correlation between titres and severity of MG, and AChR antibody titre has not been shown to be a reliable prognostic biomarker.2

    Abbreviations

    AChR, acetylcholine receptor; MG, myasthenia gravis.

    References

    1. Rousseff RT. J Clin Med. 2021;10:1736.
    2. Fichtner ML, et al. PLoS One. 2022;17:e0264489.
    Question 4/5
    Your patient with gMG has continued to progress on their current treatment and has asked you if complement inhibitors may help them. What can you tell them about the clinical data of complement inhibitors in gMG?

    C5, serum complement component 5; gMG, generalized myasthenia gravis; MG-ADL, myasthenia gravis activities of daily living.

    Complement inhibitor therapies that target C5 have shown positive results in trials of gMG.1–3 Eculizumab demonstrated a 75% reduction in exacerbation rate, with sustained MG-ADL improvements.1 Ravulizumab gave improvements in MG-ADL, with improvement seen within 1 week, maintained over 26 weeks compared with placebo,2 while zilucoplan has also demonstrated rapid and clinically meaningful improvements in MG-ADL compared with placebo.3

    Abbreviations

    C5, serum complement component 5; gMG, generalized myasthenia gravis; MG-ADL, myasthenia gravis activities of daily living.

    References

    1. Muppidi S, et al. Muscle Nerve. 2019;60:14–24.
    2. Vu T, et al. NEJM Evid. 2022;1. doi: 10.1056/EVIDoa2100066.
    3. Howard JF, et al. Lancet Neurol. 2023;22:395–406.
    Question 5/5
    Your patient has previously received treatment for NMOSD, but this was insufficient to control their disease. What action must you take before initiating a complement inhibitor?

    NMOSD, neuromyelitis optica spectrum disorder.

    C5 inhibition impairs formation of the MAC, which increases the risk of meningococcal infections.1 Patients therefore must be vaccinated against meningococcal disease ≥2 weeks prior to their first dose, or receive prophylactic antibiotics until 2 weeks after vaccination.2 All treatment decisions for NMOSD should consider prior therapies, comorbidities and disease severity.3

    Abbreviations

    C, serum complement protein; MAC, membrane attack complex; NMOSD, neuromyelitis optica spectrum disorder.

    References

    1. Asavapanumas N, et al. Expert Opin Biol Ther. 2021;21:1073–86.
    2. Frampton JE. Drugs. 2020;80:719–27.
    3. Paul F, et al. Neurol Neuroimmunol Neuroinflamm. 2023;10:e200124.
    Back to Activity

    You may also be interested in...

    touchTALKS

    Understanding the pathophysiology of multiple sclerosis and the development of new therapies

    This activity is CE/CME accredited
    LAUNCH ACTIVITY

    touchPANEL DISCUSSION

    Considerations for the selection of disease-modifying treatments in SMA: A case-based discussion

    This activity is CE/CME accredited
    LAUNCH ACTIVITY

    CONFERENCE HUB

    Shekita Green, Rare Disease Day 2022: Living with neuromyelitis optica spectrum disorder (NMOSD) – A patient perspective

    GO TO HUB

    JOURNALS

    Subcutaneous Immunoglobulin Therapy for Preventing Relapse and Maintaining Functional Ability in Chronic Inflammatory Demyelinating Polyneuropathy

    GO TO ARTICLE
    Quan.png

    JOURNALS

    Evaluation and Treatment of Neurogenic Bowel Dysfunction – A Review

    GO TO ARTICLE
    Restless legs syndrome is in the genes

    CONFERENCE HUB

    Restless legs syndrome is in the genes

    GO TO HUB
    This Activity Is Funded By:

    An independent medical education grant from Alexion Pharmaceuticals.
    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: 17 August 2023. Date credits expire: 17 August 2024.

    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