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To the Editor.— I read with interest the article on retropsoas and subgluteal abscesses (237:892, 1977). Spreading infection from the endocervical canal can also be a source of subgluteal abscess, as evidenced in a patient of ours two years ago. This young woman had an intrauterine device (IUD) in place, and a Bacteroides infection in the endocervical canal developed; it spread into the adjacent paracervical tissue and caused a severe pain in her left hip when walking. She saw an orthopaedic surgeon who noted a swelling in the left buttock, and in due course he admitted her to the hospital and drained a subgluteal abscess. The cultures recovered the same organism as those taken from the endocervical canal in and about the area of the IUD. We ultimately had to redrain the abscess in the subgluteal area on two different occasions. It was only with long-term intravenous antibiotics therapy and

• We studied the morbidity associated with steel needles used for intravenous therapy in adults with hematologic malignancy. Of 148 needles, 52 (36.1%) produced local inflammation, increasing with placements exceeding 24 hours, use of dextrose-containing infusate or intravenous antibiotics, granulocytopenia, and local infection. Eight needles (5.4%) caused local infection and three (2.1%) caused septicemia. Of nine bacteremias occurring in the 43 study patients, none of the five caused by Gram-negative bacilli, but three of the four caused by staphylococci, originated from steel needles. Five of eight local infections and all septicemias occurred with placements exceeding 72 hours (P =.016); each patient with septicemia was granulocytopenic. Intravenous steel needles are a major source of morbidity in patients with granulocytopenia or who are otherwise immunologically compromised. The insertion site should be routinely rotated at least every three days. Nosocomial staphylococcal bacteremia in granulocytopenic patients is likely to be due to an intravenous needle or similar device used for vascular access. (Arch Intern Med 140:31-34, 1980)

In Reply.— I agree with Drs Blackhall, Brody, and Tomlinson. We should discuss advance directives, including CPR, with our patients and their families. The question I raise is whether we must discuss CPR before writing a DNR order for severely demented patients or patients for whom CPR is futile. The policy I propose should not imply that we curtail communication with patients and families. Simply writing a DNR order does not excuse the physician from discussing life-sustaining therapies (feeding tubes, intravenous antibiotics, emergency surgery, and so on) that can profoundly alter the last months or years of our patients' lives. When these issues are addressed, a discussion of CPR will follow. Dr Blackhall suggests that the decision to withhold CPR because of poor quality of life can be made only by patients and their families. In most cases, I agree. But what about the severely demented patient, bedbound with decubitus

A 25-year-old man demonstrated a complete dislocation of the tibiotalar joint, caused by an axial loading injury in which he had fallen to the ground with his foot and ankle in supination. This was associated with disruption of the lateral ligamentous complex. Management consisted of immediate reduction, intravenous antibiotics, formal debridement, and ankle immobilization in a short leg cast. Early and delayed follow-up evaluations have revealed no complications resulting from the injury. Only seven cases of open posterior medial tibiotalar dislocation seem to have been reported previously in the literature.