R Voltz

University of Cologne, Köln, North Rhine-Westphalia, Germany

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Publications (228)614.31 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Objective: Research findings suggest that patients severely affected by multiple sclerosis benefit from palliative care. Our objectives were to (1) implement a pilot palliative care counseling hotline for severely affected multiple sclerosis patients and their caregivers in order to connect them to palliative care, and (2) evaluate its preliminary feasibility through a pilot study. Method: The hotline was designed in cooperation with the local state association of the German Multiple Sclerosis Society and based on a review of the literature. The initial study setting for the hotline was the broader region of the cities Cologne and Bonn in Germany. The hotline was introduced through a magazine published by the German Multiple Sclerosis Society and leaflets sent to local healthcare providers. Calls were conducted using a semistructured interview guide and documented by a standardized case report form. Measures to assess feasibility were both quantitative (e.g., number of calls) and qualitative (e.g., criteria for eligibility for palliative care). Results: During its pilot year, the hotline received 18 calls. Some 15 callers were included in the analysis, and 10 of these 15 were deemed eligible for palliative care due to such criteria as medical characteristics, care or nursing conditions, caregiver strain, and concerns regarding death and dying. Access to palliative care services could be provided for all 10 callers. Significance of results: Based on our pilot feasibility study, the hotline seems to be a valuable service for patients severely affected by multiple sclerosis (MS) and their caregivers in order to gain information about and access to palliative care. It will be extended on a nationwide scale through a grant of the German Multiple Sclerosis Society. Awareness of the hotline needs to be enhanced in order to attract and support a significant number of new callers.
    Palliative & supportive care. 09/2014;
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    ABSTRACT: Glioblastoma (GBM) patients have many palliative care (PC) issues. To date, there are no studies examining the prospective usage of validated PC assessment tools as patient reported outcome measures for GBM patients.
    Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer. 08/2014;
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    ABSTRACT: This study aims to assess and improve communication education for medical students in palliative care (PC) with the use of simulated patients (SP) in Germany. More specifically, to explore how students evaluate the use of SP for end-of-life communication training and which fears and barriers arise. A pilot course was implemented. Qualitative content analysis was used to analyse transcribed recordings of the course. Pre- and post-course questionnaires containing open-ended questions ascertained students' motivation for participating, their preparation within their degree programme and whether they felt they had learned something important within the course. Seventeen medical students in their third to fourth year of education (age 22-31) participated in the five-session course and answered the questionnaires (pre n = 17, post n = 12). Students felt insufficiently prepared and insecure. Discussing end-of-life issues was experienced as challenging and emotionally moving. Within the conversations, although students sometimes showed blocking behaviour in reaction to emotional impact, they valued the consideration of emotional aspects as very important. The course was overall highly appreciated and valued as being helpful. The communication situation with the SP was perceived as authentic. Ten out of 12 students confirmed to have learned something important (post course). Our results indicate an urgent need for better communication training for medical students. Due to the fact that bedside teaching in PC is not feasible for all students, training with standardized SP can be a way to generate an authentic learning situation. Techniques to address fears and blocking behaviour should, however, also be considered.
    Journal of cancer education : the official journal of the American Association for Cancer Education. 08/2014;
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    ABSTRACT: Background: Epidemiological data shows an increasing number of people affected by dementia. It is mentioned that people with severe dementia have special care needs which are intensified at the end-of-life. Objective: This paper offers a systematic analysis of the current status of research on the needs of people with severe dementia in the last phase of their lives. Methods: A systematic review of the MEDLINE, CINAHL, Cochrane Library, PsycINFO, and AMED databases performed up to April 2014 was further expanded by contacting experts, conducting internet searches, and screening relevant reference lists. Studies were screened according to defined criteria and appraised for methodological quality. Findings were then synthesized using a narrative thematic approach to identify and categorize relevant needs into thematic categories and subcategories. Results: A total of ten studies published from 1993-2013 were identified, encompassing qualitative (n = 7), quantitative (n = 2), and a mixed-methods study (n = 1). Data synthesis yielded seven themes, with physical, social, and psychological needs the categories most frequently mentioned. Other categories were spiritual, supportive, and environmental needs and needs related to individuality. Needs were often named, but what they entailed operationally was not highlighted in detail. Conclusion: This systematic review shows the paucity of empirical findings on the needs of people with severe dementia. The structured presentation of thematic categories points to a clearer delineation of these needs. Thus, this overview emphasizes the topics for future research and can likewise serve as an orientation for care provision.
    Journal of Alzheimer's disease: JAD 08/2014; · 4.17 Impact Factor
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    ABSTRACT: Abstract Background: Patients severely affected by multiple sclerosis (MS) present with complex symptoms and needs requiring an interdisciplinary care approach. Objective: Analysis of when and why specialized palliative care integration would be beneficial via examining health care professionals' attitudes. Design: A two-round online Delphi study and expert workshop were undertaken and analyzed descriptively. Setting/Subjects: Following an extensive online search, 164 professionals with expertise in treating and caring for severely affected patients with MS were contacted. Professionals included neurologists, urologists, general practitioners, MS nurses, speech therapists, physiotherapists, psychologists, and palliative care physicians. Forty-six consented to participate: 33 of 46 (71.4%) and 15 of 33 (45.5%) experts responded in the first and second round, respectively. Results: Consensus was reached among all respondents (100%) defining the term "severely affected": 78.8% and 86.7%, respectively, thought that specialized palliative care should begin once the disease has progressed (Expanded Disability Status Scale [EDSS]>6 and nursing care required). When the need exists for communication about disease progression (93.3%), psychological support (93.3%), relatives support (93.3%), and pain medication (86.7%) specialized palliative care should be consulted. Specialized palliative homecare was rated (93.3%) "very important." The workshop documented the paucity of home visits and specialized MS care in nursing homes. Conclusions: Our results clearly identified specific areas in which palliative care will likely prove to be a valuable asset in the treatment course of MS. This information should serve clinicians, indicating when to consider palliative care services and help further reduce or eliminate uncertainty about how palliative care can be integrated in the course of MS.
    Journal of palliative medicine. 07/2014;
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    ABSTRACT: Advance directives (ADs) are assumed to reflect the patients' preferences, even if these are not clearly expressed. Research into whether this assumption is correct has been lacking. This study explores to what extent ADs reflect the true wishes of the signatories.
    BMC Medical Ethics 06/2014; 15(1):52. · 1.71 Impact Factor
  • 10. Kongress der Deutschen Gesellschaft für Palliativmedizin und 13. Deutscher Kongress für Versorgungsforschung, Düsseldorf, 24. – 27. Juni 2014, Düsseldorf, Germany; 06/2014
  • 10. Kongress der Deutschen Gesellschaft für Palliativmedizin und 13. Deutscher Kongress für Versorgungsforschung, Düsseldorf, 24. – 27. Juni 2014, Düsseldorf, Germany; 06/2014
  • 10. Kongress der Deutschen Gesellschaft für Palliativmedizin und 13. Deutscher Kongress für Versorgungsforschung, Düsseldorf, 24. – 27. Juni 2014, Düsseldorf, Germany; 06/2014
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    ABSTRACT: Fragestellung: Schwer von MS betroffene Patienten stellen eine heterogene Gruppe mit sehr unterschiedlichen Bedürfnissen dar. Um diese Patientengruppe optimal zu versorgen, müssen ihre spezifischen Bedürfnisse identifiziert werden. Hierzu ist die Selbsteinschätzung des Patienten bei der Ausprägung der subjektiv empfundenen Schwerbetroffenheit wichtig. Methodik: In einer deutschlandweiten quantitativen Untersuchung von schwer betroffenen Patienten wurden spezifische Bedürfnisse in 25 verschiedenen Kategorien erfragt. Eine zusätzliche Single-Item Frage identifizierte Patienten, die sich stark (≥7, Median-Split) und weniger stark (< 7) subjektiv schwer betroffen fühlten (Skala 1 – 10). Unterschiede in den Bedürfnissen dieser beiden Subgruppen wurden mittels Chi-Quadrat und Mann-Whitney-U-Tests analysiert. Ergebnisse: Von 573 Patienten (Alter 20 – 83 Jahre) fühlten sich 358 (62,48%) stark schwer betroffen. Verglichen mit denen, die sich weniger stark betroffen fühlten, stuften sie die Beanspruchung für ihre Angehörigen höher ein (p < 0,001), waren öfter auf Hausbesuche angewiesen (p < 0,001), und hatten keinen festen niedergelassenen Neurologen (p = 0,016). Auch fanden sie, dass ihr Neurologe sie nicht ausreichend oft zu Hause besucht (p < 0,001). Des Weiteren unterschied sich die Gruppe ≥7 in ihrem Bedürfnis nach mehr emotionaler Unterstützung durch ihren Pflegedienst (p = 0,006). Schlussfolgerung: Die analoge Skala zur Selbsteinschätzung der subjektiven Betroffenheit identifizierte zwei Patientengruppen mit unterschiedlichen Bedürfnissen. Die Ergebnisse zeigen einen Zusammenhang zwischen der subjektiven Betroffenheit und den empfundenen ungestillten Bedürfnissen auf. Diese Daten können helfen, auf den individuellen Patienten angepasste Versorgungsstrukturen anzubieten. Es wird deutlich, wie wertvoll Palliativversorgung als ergänzende Versorgungsstruktur sein kann, um mithilfe des multidisziplinären Teams den komplexen Bedürfnissen schwer betroffener MS-Patienten zu begegnen.
    10. Kongress der Deutschen Gesellschaft für Palliativmedizin und 13. Deutscher Kongress für Versorgungsforschung, Düsseldorf, 24. – 27. Juni 2014, At Düsseldorf, Germany; 06/2014
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    ABSTRACT: Fragestellung: In Interview-Studien des Zentrums zeigte sich, dass es Palliativpatienten schätzen, ihre Erfahrungen weiter zu geben und durch die Forschung zu einer verbesserten Versorgung anderer Patienten beizutragen. Gesunde Menschen erhalten durch die Befragung von Palliativpatienten die Chance, von deren existentiellen Erfahrungen zu lernen. In unserer Studie fragten wir Palliativpatienten, was sie als aktuell wichtig erachten, ob sich durch die Krankheit etwas in ihrem Leben verändert hat und es etwas gibt, dass sie gesunden Menschen weitergeben möchten. Methodik: Patienten in stationärer palliativmedizinischer Betreuung wurden anhand qualitativer, teil-narrativer Interviews befragt. Die Gespräche wurden auf Tonband oder Film aufgenommen, transkribiert und mittels qualitativer Inhaltsanalyse kodiert. Die Patienten erhielten ihr Gespräch anschließend als CD oder DVD. Ergebnisse: 15 Interviews wurden ausgewertet: 11 Audio (10w/1 m), 4 Video (4 m), Alter: 41 – 77 Jahre. Aktuell wichtig waren den Patienten u.a.: somatische Belastungen, Ressourcen für den positiven Umgang mit der Erkrankung, die Regelung von Angelegenheiten sowie Familie/Freunde. Durch die Krankheit hatte sich geändert, sich mehr Zeit für sich zu nehmen, den Augenblick zu genießen, gelassener zu sein und sich Familie und Freunden zu widmen. Hieran knüpften die Ratschläge an die Gesunden an: eigene Bedürfnisse beachten, das Leben individuell gestalten, sich (frühzeitig) mit Krankheit und Sterben auseinander setzen und sich um Mitmenschen kümmern. Patienten und auch Angehörige schätzten es sehr, eine Aufnahme ihres Interviews zu erhalten. Schlussfolgerung: In den Interviews wurde betont, achtsamer sich selbst und nahestehenden Menschen gegenüber zu sein, los zu lassen und bewusst im Augenblick zu leben. Anschließende Studien sollten den Einsatz dieser Interviews sowohl bei Patienten und Angehörigen, in der Öffentlichkeitsarbeit als auch in der Ausbildung von Health Professionals untersuchen.
    10. Kongress der Deutschen Gesellschaft für Palliativmedizin und 13. Deutscher Kongress für Versorgungsforschung, Düsseldorf, 24. – 27. Juni 2014, At Düsseldorf, Germany; 06/2014
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    ABSTRACT: Fragestellung: Schwer von Multiple Sklerose (MS) betroffene Patienten leiden an sehr komplexen Symptomen, die einen multidisziplinären Behandlungsansatz erfordern. Palliativmedizin (PM) kann einen wertvollen ergänzenden Beitrag zur Linderung der komplexen Bedürfnisse leisten. Unklar sind jedoch noch die Kriterien, wann ein Einbezug sinnvoll ist sowie welche konkreten Versorgungsaufgaben PM mit übernehmen könnte. Methodik: In zwei webbasierten Delphi-Runden wurden Versorger schwer betroffener MS-Patienten im Raum Köln/Bonn zur Versorgungssituation befragt. Ein Experten-Workshop wurde im Rahmen des Projektes ebenfalls durchgeführt. Ergebnisse: 164 Health Professionals (Neurologie, Pflege, Physiotherapie, Palliativmedizin, Sozialarbeit, Psychologie, Urologie, Logopädie, Ergotherapie, Allgemeinmedizin) wurden kontaktiert; 46 gaben ihr Einverständnis.In Runde 1 nahmen 33/46 (71,4%) teil, in Runde 2 15/33 (45,5%). 86,7% erachten den Einbezug spezialisierter Palliativversorgung (PV) bei einem EDSS > 6 und Pflegebedürftigkeit für sinnvoll. 93,3% finden, dass PM dann integriert werden sollte, wenn das Bedürfnis besteht, über eine mögliche Krankheitsverschlechterung zu sprechen. Des Weiteren sollte spezialisierte PV zur psychologischen Unterstützung (93,3%); Angehörigenbetreuung (93,3%) und Schmerztherapie (86,7%) konsultiert werden. Der Einbezug ambulanter PV wurde von 93,3% als sehr wichtig eingeschätzt. Im Workshop wurde deutlich, dass spezialisierte PV z.B. bei einem EDSS ≥8, bei Beginn des Verabreichens von Mitoxantron sowie bei Einschränkung des Aktionsradius einbezogen werden sollte. Schlussfolgerung: Unsere Ergebnisse zeigen erste Kriterien und Aufgaben, in denen PV als wertvolle Ergänzung in der Behandlung von schwer betroffenen MS Patienten erachtet wird. Diese Informationen können Health Professionals dazu dienen, besser einzuschätzen, wann ein Einbezug von PM in den Behandlungsverlauf bei MS wichtig wäre.
    10. Kongress der Deutschen Gesellschaft für Palliativmedizin und 13. Deutscher Kongress für Versorgungsforschung, Düsseldorf, 24. – 27. Juni 2014, At Düsseldorf, Germany; 06/2014
  • 8th World Research Congress of the European Association for Palliative Care (EAPC): Lleida, Spain 5–7 June 2014, Lleida, Spain; 06/2014
  • 8th World Research Congress of the European Association for Palliative Care (EAPC): Lleida, Spain 5–7 June 2014, Lleida, Spain; 06/2014
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    ABSTRACT: Objective: Reliable and validated instruments are needed in order to study the desire for hastened death (DHD). As there is no instrument in the German language to measure DHD, our aim was to validate a German version of the Schedule of Attitudes Toward Hastened Death (SAHD-D). Method: The SAHD was translated following guidelines promulgated by the European Organization for Research and Treatment of Cancer (EORTC). In eligible patients (clinical situation adequate, MMSE ≥21), the following instruments were employed: a symptom checklist (HOPE), the HADS-D (Hospital Anxiety and Depression Scale), the EORTC-QLQ-PAL15, and the SAHD-D, as well as an external estimation of DHD provided by the attending physician. A high level of DHD was defined as the mean plus one standard deviation (SD). Results: Of the 869 patients assessed, 92 were eligible for inclusion (66% females, mean age of 64.5 years). The SAHD-D total score ranged from 0 to 18, with a mean of 5 and a standard deviation (SD) of 3.7. A high level of DHD was found in 20% (n = 19). For discriminant validity, significant correlations were found between the SAHD-D and depression (r rho = 0.472), anxiety (r rho = 0.224), and clinical state (r rho = 0.178). For criterion validity, the external estimate of DHD showed a low significant correlation with patient score (r rho = 0.290). Factor analysis of the SAHD-D identified two factors. Significance of results: Validation of the SAHD-D illustrated good discriminant validity, confirming that a desire to hasten death is a construct separate from depression, anxiety, or physical state. The unidimensionality of the SAHD could not be reproduced. Our findings support the multifactorial interdependencies on DHD and suggest that the SAHD-D should be refined by considering actual wishes, general attitudes, and options of patients.
    Palliative & supportive care. 05/2014;
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    ABSTRACT: Objective: People feeling severely affected by multiple sclerosis (MS) comprise a heterogeneous group, and this heterogeneity leads to very distinct needs and makes planning for needs difficult. To provide optimal care, it is important to identify specific needs in specific subgroups. Our objective was to identify the specific palliative care (PC) needs of patients who felt severely affected by the disease by analyzing their feeling (1) more or (2) less severely affected and their possible differences in expressed care needs. Method: A self-report questionnaire with 25 needs categories including 7 categories pertaining to care was applied to patients who felt severely affected by MS. An additional single question identified patients feeling more (≥7, median-split) and less (<7) severely affected. Differences were analyzed by chi-squared and Mann-Whitney U tests. The sample (N = 573) was composed of respondents who replied to an invitation by the German Multiple Sclerosis Society to participate in a survey on unmet needs of severely affected patients. Results: Of 573 patients (median age 51), 358 (62.48%) felt more severely affected. Compared to patients feeling less severely affected, they found the stress on their next of kin to be higher (p < 0.001), were in greater need of home visitation (p < 0.001), did not have permanent neurologists (p = 0.016), and felt that they visited them too rarely (p < 0.0001). They also needed more emotional support from their nursing care service (p = 0.006). Significance of results: A self-rating scale can identify two groups of patients with different care needs. These data may help shaping patient-centered support structures. Palliative care, with its multidisciplinary approach, might be one further option to meet the specific needs of patients and their relatives.
    Palliative & supportive care. 05/2014;
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    ABSTRACT: A survey was performed to assess whether authors who report about palliative treatments or palliative care share a common understanding of 'curative' treatments.
    Current opinion in oncology 05/2014; · 4.09 Impact Factor
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    ABSTRACT: In Germany, patients severely affected by Multiple Sclerosis (MS) do not routinely come into contact with palliative care, even if possibly beneficial. This study was aimed at investigating how severely affected MS patients and their health professionals perceive palliative care to determine how to better approach these patients in Germany about this topic. 15 patients feeling severely affected by MS and 23 health professionals experienced with MS patients (3 social workers, 7 nurses, and 13 physicians) in both in-/outpatient and rural/ urban settings participated in this qualitative study in Germany. Semi-structured interviews (patients, health professionals) and focus groups (health professionals) were conducted, transcribed verbatim and analyzed via qualitative content analysis. MS patients were mostly unfamiliar with the term "palliative care" or were aware of it only in relation to cancer and dying. They did not view it as relevant to themselves. Health professionals predominantly associated palliative care with dying cancer patients, if familiar with it at all. Most physicians doubted its relevance for neurological patients and denied MS as a cause of death. Nevertheless, most felt they already offered their patients sufficient palliative care, or thought that it could not meet MS patients' complex needs. Most nurses and social workers recognized deficits in existing care structures and regarded palliative care as an opportunity for MS patients. MS patients', and health professionals' restricted, death-associated awareness of palliative care leads to discomfort, fear or rejection of this idea. Therefore, a defined concept of palliative care emphasizing opportunities for severely affected MS patients and considering early integration should be spread throughout the German MS community as an additional layer of support for this patient group.
    BMC Palliative Care 03/2014; 13(1):11. · 1.12 Impact Factor
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    ABSTRACT: Breathlessness is a common and distressing symptom in patients with advanced disease. Patients' self-report is deemed to be the most valid method of symptom assessment. When patients are not capable of self-assessment, professionals' assessment is often used as alternative but evidence on the validity is conflicting. The aim of this study was to compare self- and professionals' assessment of breathlessness regarding presence and severity in patients with advanced disease. Secondary analysis of a cross-sectional, multi-centre and nationwide register (HOspice and Palliative Care Evaluation (HOPE)). Documented inpatients from hospices and palliative care units from 2006 to 2008 who completed the self-assessed MInimal DOcumentation System (MIDOS) were included. Professionals' assessment were based on the integrated symptom and problem checklist (symptom scores, 0-3). Cohen's kappa (κ) was used to estimate the 'level of agreement' (LoA). Two thousand six hundred twenty-three patients (mean age, 66.9 (SD, 12.8); 54.4 % female; median Eastern Cooperative Oncology Group score, 3; 95.9 % with malignant disease) were analysed. Prevalence of breathlessness was 53.4 % (1,398 patients) by professionals' and 53.1 % (1,410 patients) by self-assessment. Presence was correctly evaluated by professionals in 80.9 % of cases (sensitivity, 81.8 %; specificity, 79.8 %). Severity of breathlessness was correctly estimated in 65.7 % of cases. LoA was good (κ = 0.62) for the evaluation of presence of breathlessness and moderate (κ = 0.5) for the estimation of severity. The proportion of over- or underestimated scores was similar. If patient's self-rating, the gold standard of symptom assessment, is not possible, professionals' assessment might be a valid alternative, at least for assessing the presence of breathlessness.
    Supportive Care in Cancer 02/2014; · 2.09 Impact Factor
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    ABSTRACT: Abstract Background: The needs of patients feeling severely affected by multiple sclerosis (MS) have rarely been investigated. However this is essential information to know before care can be improved, including adding palliative care (PC) services where helpful. Since it remains unclear at what point specialized palliative care should begin for this patient group, this study focuses on needs in general. Objective: The objective was to explore the subjectively unmet needs of patients feeling severely affected by MS. Methods: The study used a qualitative cross-sectional approach for needs assessment. Fifteen patients self-reporting feeling severely affected by MS were recruited and interviewed using a combination of purposive and convenience sampling (five were accompanied by a caregiver relative). Interviews were recorded and transcribed verbatim, followed by qualitative content analysis. Results: Unmet needs were identified in the main categories "support of family and friends," "health care services," "managing everyday life," and "maintaining biographical continuity." Patients expressed the desire for more support from their families and to be viewed as distinct individuals. They see a substantial deficit in the physician-patient relationship and in the coordination of services. A decrease in expressed unmet needs was found for patients more severely affected and less socially integrated. Conclusions: To address the unmet needs of severely affected MS patients, health care services need to be improved and linked with existing PC services. Special attention is required to form supporting professional-patient relationships. Multiprofessional services should be accessible for patients, while integrating relatives. All services should have an individual approach to provide needs-tailored support.
    Journal of palliative medicine 02/2014; · 1.84 Impact Factor

Publication Stats

3k Citations
614.31 Total Impact Points

Institutions

  • 2006–2014
    • University of Cologne
      • Center for Palliative Medicine
      Köln, North Rhine-Westphalia, Germany
    • MediaPark Klinik Köln
      Köln, North Rhine-Westphalia, Germany
    • Haukeland University Hospital
      • Department of Neurology
      Bergen, Hordaland Fylke, Norway
    • Max Planck Institute for Human Cognitive and Brain Sciences
      Leipzig, Saxony, Germany
  • 2013
    • Universitätsklinikum Tübingen
      Tübingen, Baden-Württemberg, Germany
  • 1993–2013
    • Ludwig-Maximilian-University of Munich
      • • Interdisciplinary Centre for Palliative Medicine
      • • Institute for Clinical Neuroimmunology
      • • Department of Urology
      • • Institute of Clinical Neuroimmunology
      • • Department of Neurology
      München, Bavaria, Germany
  • 2011
    • Centrum für Integrierte Onkologie
      Köln, North Rhine-Westphalia, Germany
    • University of Padova
      • Department of Neurosciences
      Padova, Veneto, Italy
  • 2010–2011
    • Universitätsklinikum Erlangen
      • Department of Palliative Medicine
      Erlangen, Bavaria, Germany
  • 2009
    • University of Tuebingen
      Tübingen, Baden-Württemberg, Germany
  • 2008–2009
    • Universität Heidelberg
      • Neurological Clinic
      Heidelberg, Baden-Wuerttemberg, Germany
    • University of Bonn
      • Department of Neurobiology
      Bonn, North Rhine-Westphalia, Germany
  • 2007
    • Hospital Havelhoehe
      Berlín, Berlin, Germany
  • 2003–2005
    • University of Leipzig
      • Department für Nuklearmedizin
      Leipzig, Saxony, Germany
  • 2004
    • Universität Regensburg
      Ratisbon, Bavaria, Germany
    • Institut Marqués, Spain, Barcelona
      Barcino, Catalonia, Spain
  • 1990–2001
    • University Hospital München
      München, Bavaria, Germany
  • 2000
    • Weill Cornell Medical College
      • Division of Neurobiology
      New York City, New York, United States
  • 1997–1999
    • Memorial Sloan-Kettering Cancer Center
      • Department of Neurology
      New York City, NY, United States
  • 1996–1997
    • University of Milan
      • Department of Neurological Sciences
      Milano, Lombardy, Italy
    • San Raffaele Scientific Institute
      Milano, Lombardy, Italy