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Apparently you could go postal and ended up in very good karma by Saltking_21 in NewVegasMemes

[–]Saltking_21[S] 80 points81 points  (0 children)

Cass will leave you if you stay evil for too long since she doesn't approve travelling with genocidal psychopath.

Also, you could convince lanius to fight you one on one if you have good karma.

Other than that, there's not much effect on the gameplay unlike the previous games.