APPENDICES TO PART ONE

SCALE FOR ASSESSING THE DEGREE OF DISABILITY OF VICTIMS OF MEDICAL ACCIDENTS, IATROGENIC CONDITIONS OR NOSOCOMIAL INFECTIONS REFERRED TO IN ARTICLE D. 1142-2

VII. - CARDIOVASCULAR SYSTEM

Whatever the nature and origin of the cardiovascular lesion, the assessment of the attributable deficit must be based firstly on the functional manifestations, the importance of which can be graded by referring to the NYHA (New York Heart Association) classification.

This functional assessment will be validated by a clinical examination and analysis of all the para-clinical tests already carried out (ECG, transthoracic ultrasound, or even transoesophageal ultrasound, holter, Doppler, stress test, catheterisation, angiography, etc.) or that the expert may request or carry out if they are not invasive.

The therapeutic constraint and the monitoring it imposes should also be taken into account.

I. - Cardiological sequelae

II. - Vascular sequelae

A. - Arterial sequelae

The principles for assessing sequelae are identical to those described in the chapter on cardiological sequelae, taking the degree of claudication as the functional reference.

For amputations, refer to the "Musculoskeletal System" chapter.

B. - Venous sequelae

These are objective sequelae of unquestionable and imputable phlebitis which must be assessed taking into account any previous condition.

In the event of permanent and objective sequelae of pulmonary embolism (pulmonary perfusion-ventilation scintigraphy, PAH), the impact on respiratory function must be taken into consideration.

III. - Prostheses

The rates proposed in the case of vascular or valvular prostheses or endoprostheses (stents, etc.) should be based on the same analysis, as prostheses are not in themselves grounds for a rate increase.

The same applies to the possibility of an implantable pacemaker or automatic defibrillator.

IV. - Parietal sequelae

Persistent painful parietal sequelae (thoracotomy, sternotomy): 0 to 5%.

VIII. - RESPIRATORY SYSTEM

The assessment of permanent disability must be based on the extent of chronic respiratory insufficiency, whether in the case of sequelae of thoracic trauma (multi-costal fractures, pleural effusions, diaphragmatic lesions, lung resections), tracheal damage (stenosis), bronchopulmonary damage (asthma, chronic obstructive pulmonary disease (COPD), emphysema, pulmonary fibrosis, other conditions).

Respiratory failure is assessed at a distance from an acute episode on the basis of :

The degree of dyspnoea, which can be graded using Sadoul's dyspnoea scale (from 1 to 5);

Clinical examination;

Analysis of the various paraclinical examinations already carried out (imaging, endoscopy, gasometry, etc.) or that the expert may request or carry out if they are not invasive (FEV1/CV, DEM, CPT, CV, TLCO/VA, Sa O2, etc.) (2).

I. - Chronic respiratory failure

Assessment should always take account of pre-existing respiratory function.

If there is a discrepancy between respiratory complaints and normal resting functional parameters, a 6-minute walk test may be performed and/or an exercise test (with VO2 max) if there are no contraindications.

Dyspnoea on heavy exertion with minor impairment of one of the functional tests: 2 to 5%.

Dyspnoea when climbing a flight of stairs, walking briskly or on a gentle slope with :

- either CV or CPT between 70 and 80% ;

- or FEV1 between 70 and 80% ;

- or TLCO/VA between 60 and 70%: 5 to 15%.

Dyspnoea on normal flat walking with :

- either CV or CPT between 60 and 70% ;

- or FEV1 between 60 and 70% ;

- or TLCO/VA less than 60%: 15 to 30%.

Dyspnoea when walking on level ground at own pace with :

- either CV or CPT between 50 and 60% ;

- or FEV1 between 40 and 60% ;

- or resting hypoxaemia (Pa O2) between 60 and 70 mm Hg: 30 to 50%.

Dyspnoea on the slightest exertion (undressing) with :

- either CV or CPT less than 50% ;

- FEV1 less than 40%; or

- or hypoxaemia of less than 60 mm Hg, whether or not associated with a capnia problem (Pa CO2), possibly requiring long-term oxygen therapy (16 h/day) or a tracheotomy or intermittent ventilatory assistance: 50% or more.

II. - Asthma

Asthma can lead to disability, even though inter-critical respiratory function remains normal. This is intermittent asthma:

Not requiring background treatment: up to 5%.

Requiring background treatment: 5 to 10%.

In the event of permanent abnormality of the EFR, refer to the assessment of respiratory failure.

III. - Parietal sequelae

Persistent painful sequelae of thoracotomy: up to 5%.

IV. - Tumour pathologies

(bronchopulmonary cancer, mesothelioma, etc.)

After-effects will be assessed on the basis of residual respiratory insufficiency, any surgical procedure (thoracoscopy, pleurectomy, segmental lobar or lung exeresis) and taking into account the existence of disabling chest pain and symptoms associated with the aetiology.

Indicative rate: 15 to 60%.

IX. - HEPATO-GASTRO-ENTEROLOGY

It is only after a medical examination including detailed questioning, a complete clinical examination and a methodical study of the results of the various para-clinical investigations (X-rays, endoscopies, ultrasounds, biological tests, etc.) that the expert can judge the impact on the digestive function of a traumatic lesion, an infection or a toxic attack and assess its importance.

I. - Parietal sequelae

A. - Scar calcifications (cuttlebone)

Up to 5%.

B. - Eventrations

In the event of inaccessibility to commonly accepted surgical treatment:

Eventration of small size, causing some pain with no effect on digestive function: up to 5%.

Larger eventrations causing pain and transit problems (sometimes subocclusive phenomena), requiring the use of an appliance, depending on the size and extent of the problems: 5 to 20%.

It is exceptional to encounter major eventrations with respiratory and visceral repercussions in the context of forensic evaluation, which may justify rates of over 20%.

II. - Disorders common to different types of damage to the digestive system

Although each level of the digestive system (oesophagus, stomach, liver, gall bladder, pancreas, intestine) has its own specific symptomatology, the expert will base his assessment of the degree of disability on the extent and association of the disorders (pain, dysphagia, nausea, vomiting, flatulence, constipation, diarrhoea), the constraints they impose and their impact on the general state of health.

III. - Cutaneous stomies

IV. - Incontinence

V. - Viral hepatitis

A. - Acute

Irrespective of the virus involved, acute hepatitis usually recovers without sequelae, including prolonged forms.

Fulminant forms lead to death in 90% of cases. This incidence can only be reduced by liver transplantation (see paragraph VII).

B. - Chronic forms

Whether due to the B virus (with or without association with the Delta virus), or the C virus, the common risk is the possibility of progression to cirrhosis after a very variable period of time (from less than 10 years to 40 years).

The assessment will be based on 3 types of findings:

Serological and histological findings to assess the extent of the risks and the rate of progression to cirrhosis:

- for hepatitis B :

- serum level of viral DNA ;

- existence of an H Be antigen;

- for hepatitis C :

- significance of viral load in CRNA ;

- virus genotype ;

- for both forms :

- data from the metavir score, assessed by liver biopsy (this score is more accurate than the Knödell score in that it allows precise differentiation of the degree of fibrosis).

Clinical findings and functional manifestations.

The possibilities and results of medical treatment.

If treatment has been applied, the assessment should be carried out at least 6 months after the treatment has been stopped, regardless of its duration.

Sustained response to treatment is characterised by normalisation of the biology (ALAT) and non-detection of serum CRNA.

There are three possible outcomes

- sustained response to treatment ;

- patient who responds to treatment but relapses;

- non-responder.

Before cirrhosis:

- metavir score equal to or less than A1 F1: up to 5% ;

- metavir score greater than A1 F1, less than F4: 5 to 10%;

- metavir score equal to or greater than F4: the progression is that of cirrhosis.

In the case of documented concomitant pathological conditions which may be related to chronic hepatitis C (arthromyalgia, peripheral neuropathy, vasculitis), please refer to the relevant devices.

For certain extra-hepatic manifestations which have also been documented, the initial rate may be increased.

At the cirrhosis stage:

Rates are based on the Child classification:

- class 1: good liver function Child A: 10-20% ;

- class 2: moderate impairment of liver function Child B :

20 à 40 % ;

- class 3: advanced hepatic insufficiency Child C: 60% or more.

VI. - Hepatitis of other origin

In the event of chronic hepatitis, assessment will be based on clinical and histological disorders (see above).

VII. - Transplants

Taking into account the heavy therapeutic burden, the need for close medical supervision and tolerance of treatment: 30 to 40%.

For transplants following hepatitis B or C, the risk must be assessed differently, taking into account recurrences (25% for hepatitis B, over 90% for hepatitis C).

X. - ENDOCRINOLOGY. - METABOLISM

In common law, the medico-legal assessment of a bodily injury consisting solely of an endocrine deficiency is a rare eventuality. It often comes up against difficult problems of imputability, given the possible existence, prior to the incriminating event, of unknown biological deficits whose development was precipitated by this event.

I. - Pituitary gland

Persistent hypopituitarism is a rare complication of severe cranial trauma (around 1%). These deficits are almost never isolated, forming part of a complex sequelae.

Panhypopituitarism (anterior and posterior) requiring replacement therapy and stringent clinical and biological monitoring; depending on the effectiveness of the treatment: 25% to 40%.

Posterior hypopituitarism: diabetes insipidus well controlled by adequate treatment; depending on the efficacy of replacement therapy: 5% to 15%.

II. - Thyroid

A. - Hyperthyroidism (Graves' disease)

The definitive assessment can only be made after appropriate treatment (synthetic antithyroid drugs for 18 months, surgery, radioactive iodine, etc.).

If there are still clinical signs of thyroid dysfunction and depending on the impact on other systems :

10 % à 30 %.

B. - Hypothyroidism

Apart from idiopathic hypothyroidism, hypothyroidism may occur after treatment of hyperthyroidism by surgery or radioactive iodine.

If well balanced with replacement therapy: 5%.

III. - Parathyroid

This is essentially hypoparathyroidism which may occur after thyroidectomy.

Depending on the difficulty of balancing hypocalcaemia: 5 to 15%.

IV. - Adrenal insufficiency

Iatrogenic adrenal insufficiency, secondary to (sometimes untimely) corticosteroid treatment, may occur during withdrawal. Adrenal insufficiency thus formed requires appropriate corticosteroid therapy.

Depending on the constraints associated with treatment and monitoring: 10 to 25%.

V. - Pancreas-diabetes

A. - Non-insulin-dependent diabetes

This is never the result of a traumatic event. However, this event may bring out a latent unknown condition or temporarily aggravate a known condition which had previously been compensated for.

Appropriate treatment should enable the patient to return to his previous state. A permanent disability rating is never justified.

B. - Insulin-dependent diabetes

Insulin-dependent diabetes may appear after a traumatic event in subjects who previously had no known clinical or biological signs. It is always difficult to establish the cause, except in the case of major pancreatic lesions requiring resection of 80 to 90% of the gland (an exceptional hypothesis).

No observations of diabetes mellitus following severe cranial trauma have been reported.

If imputability is accepted :

Simple diabetes, well balanced with simple insulin treatment: 15 to 20% ;

Unstable diabetes despite monitoring and therapeutic attempts, with daily functional impairment: 20 to 35%.

In the event of complications leading to permanent sequelae, please refer to the relevant specialities.

XI. - HAEMATOLOGY AND BLOOD DISORDERS

A. - Spleen

Splenectomy without haematological abnormality: up to 5%.

Splenectomy with definitive haematological abnormalities: 5 to 10%.

In children, the existence of infectious episodes or infectious grafts should lead to postponement of consolidation.

B. - Other haematological abnormalities

These may exceptionally be the subject of a request for assessment. They are almost always reversible and therefore do not constitute a rate of partial permanent disability. In the rare cases where these abnormalities are definitive and require medical follow-up, reference should be made, for the assessment of the degree of disability, to the proposals concerning the speciality or specialities concerned by the deficits observed.

XII. - NEPHROLOGY-UROLOGY

When disorders of urinary function are part of a pathological whole, such as "neurological bladders" following spinal cord injuries, the assessment of the rate of IPP will be made globally for the clinical entity in question.

They will only be the subject of a specific assessment if they constitute the essential part of the physiological deficit giving rise to a medico-legal assessment.

I. - Nephrology

A. - Nephrectomy

Unilateral - Normal renal function: 3%.

B. - Renal failure

Creatinine clearance between 60 and 80 ml/mn with HTA 16/9 :

up to 10%.

Creatinine clearance between 30 and 60 ml/mn. HTA with a minimum of 12. Need for strict diet and medical treatment: 10 to 25%.

Creatinine clearance 30 ml/min. Impaired general condition. Very strict diet and heavy therapeutic constraints: 25 to 35%.

Creatinine clearance less than 10 ml/min. Need for in-centre haemodialysis or self-dialysis; depending on complications:

35 à 50 %.

C. - Renal transplantation

Depending on tolerance to corticosteroid and immunodepressant treatments: 20 to 30%.

II. - Urology

The proposed rates take into account complications and therapeutic constraints.

A. - Urine retention (excluding spinal cord or central pathologies)

Auto or hetero-catheterisation (3 to 6 per day): up to 15.

Indwelling catheter: 20 to 25%.

Implanted stimulator: up to 5%.

B. - Urinary incontinence

A few leaks not requiring protection: up to 5%.

Urges: up to 10%.

Regular leakage on exertion, coughing. Need for protection :

5 à 10 %.

Severe form requiring permanent padding: 20 to 25%.

Artificial sphincter: 5 to 10 %.

C. - Stenosis of the urethra with reduced urinary flow

Requiring 1 to 2 dilatations per year: up to 5%.

Requiring more than 10 dilatations per year: up to 10%.

D. - Permanent urinary diversions

Unilateral nephrostomy: 10 to 20%.

Bilateral nephrostomy: 20 to 30%.

Transileal or transcolic ureterostomy; cystostomy: 10 to 20%;

Unilateral ureterostomy with ureteral catheter, collector and bag: 15 to 20%.

Bilateral ureterostomy with ureteral catheter, collector and bag: 20 to 30%.

XIII. - PROCREATION-SEXUALITY

Impairment of the reproductive function may result from an anatomical anomaly, a physiological deficit or a dysfunction in the performance of the sexual act.

Anatomical anomalies and physiological deficiencies can be validated by clinical arguments based on standard medical techniques. These consequences are expressed by a rate of PPI. Some of them can be compensated for in both men and women by techniques of medically assisted procreation, which the expert should explain.

A. - Organ removal

Hysterectomy: 6%.

Ovariectomy :

- unilateral: 3% ;

- bilateral: 6%.

Salpingectomy :

- unilateral: 3% ;

- bilateral: 6%.

Orchidectomy :

- unilateral: 3% ;

- bilateral: 6%.

Amputation of the penis :

(taking into account the overall impairment of function): 20 to 25%.

B. - Sterility

Sterility inaccessible (whatever the cause) to medically assisted procreation techniques (rate including removal of the organ): 20 to 25%.

C. - Sexuality

Impairment in the performance of the sexual act cannot be expressed as a rate of PPI.

In order to rule on the nature and imputability of disorders of this type, the expert will have to describe them in detail, referring to the complaints expressed, the information obtained during the interview, and the results of any specialised clinical or paraclinical examinations carried out. He will compare these elements with the initial lesions and will give his opinion on the existence of the damage without pronouncing on the possible prejudice that may result from it.

D. - Special cases

In the same way as other physical injuries, a uni or bilateral mastectomy (exceptional in traumatic cases) may have repercussions on sexual life.

This impact must be described in detail by the expert.

In the event of repercussions :

- on the balance of the spine, refer to the "Rachis" chapter;

- on shoulder mobility, refer to the "Locomotor system - understanding" section.

Concerning only the loss of the organ:

- unilateral mastectomy: 5% ;

- bilateral mastectomy: 10%.

Lymphoedema: 10%.

XIV. - CUTANEOUS SEQUELAE OF SEVERE AND EXTENSIVE BURNS

Severe and extensive burns may cause specific after-effects apart from those of a purely aesthetic or psychological nature, amputations of organs and/or serious alterations to anatomical regions, and impairment of joint or sensory-motor functions, which are assessed separately.

The PPI rate proposed for these specific after-effects must essentially take into account :

- the surface area of the lesions, but also ;

- the method of repair (autologous grafts, cultures) ;

- anomalies in the grafted areas

- dysfunction in the skin's normal exchanges (thermoregulation, sweating, etc.) ;

- skin fragility (ulcers, cracks when wearing clothes, sun intolerance);

- pruritus, eczematisation, hyperkeratosis.

A PPI rate is only justified in the case of deep burns with grafting or pathological scarring.

Depending on the percentage of the lesion surface:

- less than 10%: up to 5% ;

- from 10 to 20%: 5 to 10%;

- 20 to 60%: 10 to 25%;

- over 60%: 25 to 50%.